Conservative treatment is initially indicated for
nearly all patients with hip arthritis, with surgery
being reserved for those patients in whom conservative
measures are no longer enough. Most patients have
usually progressed through the spectrum of
conservative treatment by the time they are referred to
an orthopaedic surgeon, but it is important to be aware
of the nonoperative options that can often suffice for
months or years before pain and disability are
significant enough for hip surgery.
Activity Modification
It is important to maintain as much activity and
joint motion as possible, but impact activities will
aggravate arthritis. Running and jumping will often
accelerate cartilage loss from the joint. Using an
elevator instead of stairs and avoiding uneven terrain
are helpful. However, there is significant evidence that
remaining active and keeping the hip moving will
prolong its life. Many patients worry that they should
give up walking or other low impact activities in order
to try to preserve the hips, but a sedentary lifestyle
actually will shorten the life of the hips. The key is to
focus on low impact activities, such as swimming or
cycling. These are the best forms of exercise with
arthritic hips as they do not require significant weight
bearing across the hip joints. For patients who do not
have access to a pool or a stationary bicycle, leisurely
walking will also maintain hip range of motion,
strength, and function.
Canes
Use the cane on the opposite side of
the bad (or recently operated on) leg.
Canes or walking sticks are useful, particularly
when the arthritis affects only one side. Some canes
have multiple feet or prongs (e.g., a quad cane) to
increase stability for patients with poor balance.
A surprising number of patients use canes on the
wrong side, however! It is important to use the cane in
the opposite hand from the bad hip or knee. This
allows you to lean away from the bad leg, taking weight
off of it. It is also important to adjust the height of the
cane so that the hand height rests comfortably along
your side, preventing stooping or poor posture.
Weight Loss
Significant weight loss for obese patients can make
a dramatic difference, although in actuality, relatively
few patients are successful in losing weight because
arthritis limits their ability to exercise.
Weight loss is probably the single most effective
intervention the patient can undertake on their own.
Increasingly, severely overweight patients (300+ lbs.)
are turning to bariatric surgery (e.g., gastric bypass
surgery) with promising results, although it remains a
serious operation. For the average patient who is
somewhat overweight, losing 20 lbs. or more can often
at least improve their discomfort and may delay the
need for surgery.
Weight loss is also important for increasing the life
span of a joint replacement. Surgery is also less risky
for patients who are not severely overweight. Although
in our practice we do regularly perform joint
replacements for patients even over 400 lbs., it is with
the thorough understanding that their joint
replacements may wear out more quickly, and they are
at increased risk for complications with surgery.
Surgery usually takes longer and is more challenging for
the surgeon when the patient is morbidly obese (body
mass index > 35), due to the loss of anatomical
landmarks, prolonged exposure and closure time, and
need for additional assistants at the time of surgery
Hip Injections
Injection therapies do not "cure" the underlying
problems of arthritis, but can be useful for short term
relief (potentially for a few months) and for diagnostic
purposes.
Steroid injections into the hip bursa (between the
muscle layers on the outside of the hip) are usually
quite effective for bursitis, and may be all that is
required in combination with physical therapy and antiinflammatory
medications for resolution of a patient's
symptoms. These injections do not require live x-ray,
and the injection is usually administered over the side
of the hip in the location that is most tender to
palpation.
Injection of the hip joint is a deeper injection. It
typically is quick and only takes a few minutes in the
office, but it does require the use of a live x-ray
machine (fluoroscopy) to ensure that the injection is
placed into the hip joint itself. Most surgeons inject a
local anesthetic and steroid mixture (often along with a
small amount of contrast, which can be seen on the live
x-ray). The anesthetic will often make the hip feel
immediately better and for a few hours afterwards, and
then the local anesthetic wears off. The steroid
component often may take 5 to 7 days to fully take
effect.
While injection of the arthritic hip joint itself is not
a cure, it does have several very useful roles. It is very
useful for diagnostic purposes to help determine where
a patient's primary source of pain is originating from.
Frequently patients may present with both sciatica and
hip arthritis; prior to planning hip replacement, it is
useful to see if their pain improves (even for just a
short while) by injecting the hip. Another common
scenario is that of a patient who knows that he or she
needs a hip replacement but is looking for a few
months of temporary relief (e.g., they are traveling, or
have a daughter's wedding coming up, etc.). Most
surgeons try not to use steroid too frequently as it does
have some side effects (notably, weakening of the
bones and tissues, and rarely, infection), but commonly
surgeons will consider injections a few times per year to
be acceptable.
A newer injection option on the horizon may be
hyaluronate injections. While these are commonly used
for knee injections (and discussed at length in that
section of this book), they are still considered "offlabel"
and investigational for hip arthritis at the time of
this writing. We have periodically used hyaluronate
injections into the hip for some patients with good
results, but this treatment is not usually covered by
insurance or Medicare at the present time.
Nonsteroidal Anti-inflammatory Drugs(NSAIDs)
This family of medications includes aspirin,
ibuprofen, naprosyn, and other non-narcotic
medications to decrease inflammation. They remain
the mainstay of preoperative management of arthritis
pain and are usually most useful in the early years of
developing arthritic pain.
Most patients experiment with different over-thecounter
NSAIDs before finding the one that seems to
work best for them. Older NSAIDs such as aspirin
and ibuprofen have been around for many years, and
newer drugs in this class called COX II inhibitors, such
as celecoxib (Celebrex), valdecoxib (Vioxx - now
discontinued), and meloxicam (Mobic) have recently
been introduced. Many physicians feel that these are
not much different from aspirin and ibuprofen in
effectiveness, although these medications have fewer
side effects such as gastrointestinal upset. For this
reason these more expensive drugs are usually
employed when a patient cannot tolerate traditional
over-the-counter NSAIDs, typically because of GI
upset. Some of these drugs were in the news a few
years ago (notably, Vioxx) because there was some
concern about heart problems in a small number of
patients. These drugs also require monitoring of liver
function if taken for a long period of time.
It is important not to take NSAIDs on an empty
stomach, or to use them with blood thinners (such as
warfarin) unless directed by a physician. Collectively,
these medications are responsible for many cases of GI
bleeding and ulcers in elderly patients each year. These
medications can interfere with kidney function and may
lead to swelling in the legs. These medications can also
interfere with some blood pressure medications, and it
is important to also check with the physician
prescribing the blood pressure medication before
taking any of these medications.
Although orthopaedic surgeons may provide an
initial prescription for a month or two of NSAIDs, it is
usually preferable to obtain these from your family
physician over the long term because of the need for
monitoring after several months of use. Some of these
drugs require liver function tests and other testing after
prolonged use.
Glucosamine / Chondroitin Sulfate
Glucosamine chondroitin is a "nutraceutical,"
essentially a supplement that is often found in the
vitamin aisle of the drug store or supermarket. As
such, it does not typically have to adhere to the same
labeling rules as drugs that are regulated by the FDA,
and it is not uncommon to see labels proclaiming that
it will "re-grow cartilage!" There is not much evidence
that it is likely to do anything so dramatic, although
there is compelling evidence that it is relatively safe and
works by decreasing inflammation in the joint, making
at least some patients feel better. Patients with a
shellfish allergy should use caution when taking this, as
it may cause an allergic reaction. The typical dosage is
about 1500 mg of glucosamine and 1200 mg of
chondroitin sulfate daily. Most manufacturers sell the
two mixed together in a single pill. It is not
uncommon to have to take it for two weeks or more
before a significant benefit is seen.
Narcotics ("Pain Killers")
Most hip and knee surgeons feel strongly that these
do not have a role in the preoperative management of
arthritis, and in our practice, we typically do not
prescribe them except after surgery or fracture.
Narcotics (such as oxycodone, hydrocodone,
oxycontin, etc.) are useful for treating significant pain
that is expected to get better in a few weeks. When
taken for a long period of time, they can have serious
side effects, including addiction, constipation,
confusion, and a need for higher levels of narcotics to
maintain the same level of pain relief. Additionally,
patients who have been on narcotics for any significant
time prior to surgery are typically more difficult to keep
comfortable after surgery because they have developed
a tolerance to opiates (narcotics).
Symptoms
The primary symptoms of rheumatoid arthritis are similar to osteoarthritis and include pain, swelling and the loss of motion. In addition, other symptoms may include loss of appetite, fever, energy loss, anemia, and rheumatoid nodules (lumps of tissue under the skin). People suffering with rheumatoid arthritis commonly have periods of exacerbation or "flare ups" where multiple joints may be painful and stiff.
Treatment
Treatment of rheumatoid arthritis may involve medications such as NSAIDs, aspirin and analgesics. Corticosteroids, such as prednisone may be prescribed, and are effective in decreasing the inflammation associated with rheumatoid arthritis. Side effects can occur with the use of corticosteroids, and close monitoring by a physician is essential.
Researchers have made progress in the treatment of rheumatoid arthritis and newer prescription drugs are now available. If non-surgical measures fail, you and your surgeon may decide that total hip replacement is the best treatment option to relieve your pain and help you return to an improved functional level.
Please remember the information on this site is for educational purposes only and should not be used to make a decision on a condition or a procedure. All decisions should be made in conjunction with your surgeon and your primary care provider.
