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Osteoarthritis of the hip.

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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 .
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