CURRENT METHODS OF TREATMENT Osteoarthritis of the Hip By Orno STEINBROCKER 0 STEOARTHRITIS of the hip may be part of a generalized degenerative joint disease or the secondary effect of a local, congenital or acquired abnormality. The mere presence of radiologic changes is not an indication for treatment, but it justifies the preventive measures to be discussed. Although radiologic changes may parallel the symptomatology, this is not always true. The severity of the complaints, therefore, is the chief consideration in management. Treatment of coxal arthrosis is required by the chief symptoms of pain and disability. Either of these, but pain in particular, is apt to interfere with the patient’s pursuit of happiness and occupation, sometimes with every step taken in these directions. Even before pain or, less frequently, disability, assumes such proportions, surgery may be indicated. In due time, many patients with troublesome osteoarthritis of the hip pose the problem of unresponsive, symptomatic progression for which surgical intervention remains the only solution. Pain thereby is abolished, as a rule, but disability may or may not be improved, according to the circumstances or the type of operation most suitable. Degenerative disease at the hip often proceeds to relentlessly continuous progression, with temporary, little or no response to medical management. Not infrequently, nevertheless, surgery is not indicated, must be deferred or is not practical. In spite of great discomfort and disability, some patients remain unreceptive to surgical intervention, or require a long time to accept it. It happens that osteoarthritis of the hip in many individuals runs a milder course with rather slow advancement, provoking only tolerable symptoms and functional limitations. Intermediate states between these extremes also are encountered, in which the psychological readiness of the patient and the good judgment of the physician must determine when surgery is indicated. This disease is more common after middle age, so the visceral and other complications of the older decades sometimes do not permit surgery. Changes in the opposite hip and at the lumbar spine may require multiple operations, involving prolonged hospitalization, inescapable hazards or indefinite results. A sound program of management, therefore, may prove helpful in controlling symptoms and, possibly at the early stages, in influencing the pace of alterations at the hip in subjects not requiring surgery or in those unwilling or unfit to have it. The categories of symptoms in osteoarthritis of the hip requiring medical management, then, may be listed as: 1. Mild pain, with or without disability. 2. Severe pain, with or without commensurate disability, responsive to such measures, not disrupting the activities of living and occupation. 3. Severe pain and/or disability, interfering with happiness or employment, in patients unwilling to accept surgery although fit for it, until exhaustion of medical and physical measures ( and the patient). 89 90 OTTO STEINBROCKER 4. Symptoms in individuals physically unfit for surgery. The management of osteroarthritis of the hip embodies the principles followed in the treatment of generalized osteoarthritis, with special emphasis on methods having local effects at the involved hip. General and local measures are used. These will be discussed as outlined in table 1. MINIMIZING OR PREVENTING ACTIVEOH STATICTRAUMA The most important step frequently is recognition, minimizing or elimination of provocative strain or trauma arising from occupation, habits, hobbies, daily activities such as excessive walking or stair climbing. The correction of contributory poor body mechanics or anatomic defects within sensible limits in elderly individuals, such as bad posture, shortening of an extremity with a pelvic tilt, distortion at the knees and weak arches, is also important. Orthopedic aids and corrective exercises within reasonable limits may be useful. Orthopedic consultation and guidance in complicated situations may be quite helpful. Frequently, provocative stress may be due to overweight, which must be corrected and controlled by diet, and anorectics if necessary, as a preventive as well as a therapeutic procedure. General Measures Although local therapeutic measures f a the affected joint constitute the really specific methods, general measures will be considered first because they often prove sufficient by themselves, for a while, or they usually are administered along with local procedures. Reinforcing morde frequently is an important consideration in chronic osteoarthritis of the hip, particularly for stubborn symptoms in patients iinwilling to have, or unfit for, surgery. Reassurance, explanations of the course of events, minimizing or eliminating emotional conflicts or environmental anxieties, and even formal psychotherapy, may be required, sometimes with surprising benefit. Treatment of complications in patients at the later decades naturally is apt to assist indirectly in the control of the symptom level or in keeping patients in shape for eventual surgery. The recognition and adequate care of cardiac, pulmonary, gastrointestinal, vascular or endocrinologic disorders (particularly diabetic or hypothyroid) is essential. Musculoskeletal complications in these age groups, such as involvement of the opposite hip, degenerative alteration of lumbar vertebrae and discs likely to be subjected to increased stress by the mechanical shifts brought about by hip surgery, or severe involvement of the opposite knee, must be established for adequate evaluation of the extent of the therapeutic problem and the outlook. Analgesics are the chief agents for symptom control in presurgical periods and for those who for various reasons are not candidates for surgery. The range of these preparations ultimately is exhausted in many patients, even when they are temporarily effective, owing to tolerance and unresponsiveness to maximum doses. It becomes a waste of limited resources, therefore, to discard any of these agents for unsound reasons (usually inadequate dosage trials, irregular doses or unrelated “‘reactions” not carefully confirmed). OSTEOARTHRITIS OF THE HIP 91 Table 1.-Management Program in Coxal Arthrosis Minimizing OT Prmenting Active and Static Trauma Elimination of strain or trauma of occupation, hobbies or excessive daily activities (stair climbing, walking, etc.) Correction of poor body mechanics and anatomical defects, such as Pelvic tilt, deficient posture, genu varus or valgus, weak feet. Orthopedic aids and consultation. Avoiding exposure to dampness and temperature changes. Weight reduction and control. Gene*aZ Measures Management of complications Reinforcing morale Reassurance, explanations, Minimizing emotional provocation; psychotherapy. Sedatives or relaxants. Treatment of complications. Visceral, endocrine, vascular, musculoskeletal, obesity, etc. Analgesics Salicylates, propoxyphenes, phmylbutazone, corticosteroids ( rarely and briefly). Codeine during acute episodes. Sedatives or relaxants; soporific. Rest Balanced activity and rest periods. Prolonged bed rest for acute or intractable symptonis. Local Measures Physical modalities Heat and electrotherapy. Massage. Exercises, local tensing, passive and active motions; postural when feasible. Counterirritants. Rehabilitation program in advanced cases unsuitable for surgery. Mechanical devices, especially canes or crutches; light spica. Local and regional injections Intra-articular Corticostemid suspensions, procaine, arid solutions. Periarticular injections. Caudal and paravertebral anesthetics. X-ray therapy. Manipulation. Orthopedic surgery. Salicylates are the simplest medications and should be taken regularly in adequate amounts proportionate to the pain, 3-7 grams daily, in divided doses, in plain, buffered or enteric form or with antacids when necessary. Dextropropoxyphene (Darvon) M ethohuptazine citrate (Zactane), more recent formulations, alone or with separately prescribed salicylates, may provide satisfactory relief. The doses must be sufficient in troublesome pain, 100-150 mg., during meals and at bedtime. Phenylbutazone (Butazolidin)-Alka, in 100 mg. capsule doses, q.i.d., may be effective with the usual precautions. Each of these medications tends to be a gastric irritant in some individuals, so taking them with food, or the simultaneous me of antacids, is desirable. 92 OTTO STEINBROCKW Usually accepted precautions for toxicity and contraindications are important in these older age groups. Corticosteroids during acute episodes or in refractory pain are worthy of a trial, if no contraindications are presented, to tide the patient over to the level responsive to other agents. The minimum effective dose should be used, from 10-15 mg. of prednisone or equivalents, decreased in stepwise fashion with continued responsiveness. Codeine for acute exacerbations, particularly after trauma, is warranted for short periods. Sedatives or relaxants are a necessary part of the therapeutic program in tense or disturbed individuals. A general sedative or relaxing effect appears to be helpful in many of these individuals. The use of muscle relavants as such has not been fruitful in this writer’s observations. A soporific to provide a good night’s rest is desirable when needed. Rest is an important therapeutic measure. For troublesome pain, and in less severe symptoms when patients can practically carry it out, a period of bed rest for several days, or even 7-14 days, brings the svmptoms down to a lower or bearable level. An afternoon rest period, for 1-3 hours to reduce weightbearing, is a helpful routine. Diet most frequently is aimed at weight reduction and control. Unless a patient is underweight, some weight reduction contributes to relief of the affected hip. A high-protein, low-fat, low-carbohydrate diet usually i i desirable, unless some complication imposes other considerations. Loco I Measures Phipica1 moclalities provide the simplest method of temporary relief, when effective. Any form of heat at home, dry or wet, not requiring excessive exertion is suitable. Massage, local and general, if readily accessible, is comforting. Exercises, tensing of atonic or atrophic muscles, and a routine of passive or active motions, within discreet limits, offer the most useful physical measures. Where it is practical, postural exercises are added. A rehabilitative program, in an organized form by a physical therapist, may be required in advanced cases unwilling to accept, or unfit for, surgery. Mechanical aids consist chiefly of canes or crutches, wooden or Canadian, one or two. These require persuasion to overcome a psychological barrier, but they can be most useful phvsical aids to spare the affected ioint, when surqery c a n b t be carried out. A light spica to support the painful hip is used on rare occasions. Traction is applied in stubborn cmes, b17t its effectiveness is unpredictable and of temporary value. X-rail fherapil may be used for refractorv pain, when previous measures have been exhausted. Radiation is effective only occasionally, and temporarily. Manipulntion is advocated by some observers, but it requires skillful technic and selection of cases. Locat and repionul injections have been widely applied to provide a local method of relief. OSTEOARTHRITIS OF THE HLP 93 fntraarticulur injections of corticosteroid suspensions recently have been used extensively in coxal arthrosis. The anterior or lateral approach to the joint is used. This procedure, apart from its frequent failures, has two objections, the hazard of infection and the possibility that deterioration may be accelerated. Perhaps its greatest shortcoming is that the best technician cannot be sure the injecting needle is in the articular space unless fluid is aspirated, a rare occurrence. Such injections are best reserved as a last resort for patients unfit for surgery or unwilling to accept it. The author has the impression that lasting benefit from this approach to degenerative hip disease is unlikely unless concomitant synovitis is present. Relief then follows for 1-6 weeks. Eventually this measure usually becomes ineffective. Local injections of procaine and related compounds have been introduced into periarticular points of tenderness to produce temporary relief of pain for hours or days. In acute exacerbations these may be helpful. Acid solutions alone, or with procaine, have been advocated but our experience, like others, has not shown any real benefits. Regional analgesic injections with procaine by the paravertebral or caudal ( peridural) route have been advocated. Paravertebral injections rarely are used now, because they are formidable procedures, yielding unpredictable results. Caudal injection is a simpler method, occasionally effective. If used, it should be reserved as a last resort for intractable symptoms. In summary, osteoarthritis of the hip, when severely troublesome, is likely sooner or later to present a refractory problem of pain and disability requiring surgical intervention. When the physician is convinced of the desirability of surgery, the best interests of the patient are served by overcoming the psychological block often present. If the patient is unwilling to accept surgery, or unfit for it, just as in the earlier, tolerable phases, a program of management must be combined and repeatedly modified according to the patient’s needs and responsiveness. This consists essentially of the correction and prevention of mechanical defects, general medical measures and local procedures. The proper wmbination of these makes symptoms bearable for long periods or indefinitely in some individuals. Otto Steinbrocker, M.D., Assistant Professor of Clinical Medicine, New York University Postgraduate Medical School; Chief, Department of Rheumatology, Hospital for Joint Dbeases and Lerwx Hill Hospital, New York, N . Y .