Inflammatory Arthritis of the Hip

Inflammation of the joints is called arthritis.  There are more than 100 different forms of arthritis, a disease that can make it difficult to do everyday activities because of joint pain and stiffness. 

The most common form of hip arthritis is osteoarthritis - the "wear-and-tear" arthritis that damages cartilage over time, and usually causes symptoms in people after they reach middle age.

Inflammatory arthritis occurs when the body's immune system becomes overactive and attacks healthy tissues. It can affect several joints throughout the body at the same time, as well as many other organs, such as the skin, eyes, and heart.

There are three types of inflammatory arthritis that most often cause symptoms in the hip joint:

• Rheumatoid arthritis - In rheumatoid arthritis, the synovium lining thickens, swells, and produces chemical substances that attack and destroy the articular (joint surface) cartilage covering the bone. Rheumatoid arthritis often symmetrically affects the same joint on both sides of the body, so both hips may be affected.
• Ankylosing spondylitis - Ankylosing spondylitis is a chronic inflammation of the spine and sacroiliac joints that most often causes lower back pain and stiffness. It may affect other joints, as well, including the hip.
• Systemic lupus erythematosus (SLE) - SLE can cause inflammation in any part of the body, and most often affects the joints, skin, and nervous system. The disease occurs in young adult women in the majority of cases. People with SLE have a higher incidence of osteonecrosis of the hip, a disease that causes bone cells to die, weakens bone structure, and leads to disabling arthritis.

Symptoms

Inflammatory arthritis may cause general systemic symptoms throughout the body, such as fever, loss of appetite and fatigue. A hip affected by inflammatory arthritis will feel painful and stiff. There are other symptoms, as well:

• A dull, aching pain in the groin, outer thigh, knee, or buttocks
• Pain that is typically worse in the morning or after sitting or resting for a while, but lessens with activity
• Increased pain and stiffness with vigorous activity
• Pain in the joint severe enough to cause a limp or make walking difficult

Diagnosis

The diagnosis of inflammatory hip arthritis is made by thorough history and physical examination, followed by imaging studies and blood tests.  The laboratory tests in particular look for the presence on inflammatory markers, presence of a rheumatoid factor, autoantibodies, and also some specific genetic markers.

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(Left) This x-ray shows a normal hip. (Right) This x-ray shows inflammatory arthritis with decreased joint space with little or no bone spur (osteophtye) formation.

Treatment

Although there is no cure for inflammatory arthritis, there are a number of treatment options that may help prevent joint destruction. Early diagnosis and treatment can help patients maintain mobility and function by preventing severe damage to the joint. A team of healthcare professionals, including rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons often work together to treat inflammatory arthritis.

Nonsurgical Treatment

The treatment plan for managing your symptoms will depend upon your type of inflammatory disease. Most people find that some combination of treatment methods works best.

• Non-steroidal anti-inflammatory drugs (NSAIDs) - Drugs like naproxen and ibuprofen may relieve pain and help reduce inflammation. NSAIDs are available in both over-the-counter and prescription forms.
• Corticosteroids - Medications like prednisone are potent anti-inflammatory agents. They can be taken by mouth, by injection, or used as creams that are applied directly to the skin.
• Disease-modifying antirheumatic drugs (DMARDs) - These drugs act on the immune system to help slow the progression of disease. Methotrexate and sulfasalazine are commonly prescribed DMARDs.  A number of specific biological agents are also now available and prescribed by rheumatologists to suppress the inflammatory destructive process.
• Physical therapy - Specific exercises may help increase the range of motion in your hip and strengthen the muscles that support the joint. In addition, regular, moderate exercise may decrease stiffness and improve endurance. Swimming is a preferred exercise for people with ankylosing spondylitis because spinal motion may be limited.
• Assistive devices - Using a cane, walker, long-handled shoehorn, or reacher may make it easier for you to perform activities of daily living.

Surgical Treatment

If nonsurgical treatments do not sufficiently relieve your pain/symptoms, surgery may be considered. The type of surgery performed depends on several factors, including:

• Your age
• Condition of the hip joint
• Which disease is causing your inflammatory arthritis
• Progression of the disease.

The goal of surgery is to relieve the hip pain and improve functional range of motion.

The most common surgical procedures performed for inflammatory arthritis of the hip include:

1. Total hip replacement - Total hip replacement is often recommended for patients with rheumatoid arthritis or ankylosing spondylitis to relieve pain and improve range of motion. In the procedure, the damaged cartilage and bone is removed, and then new artificial components are inserted to restore the function of your hip. 
2. Synovectomy - Synovectomy is done to remove part or all of the joint lining (synovium). It may be effective if the disease is limited to the joint lining and has not affected the articular cartilage that covers the bones. Generally, the procedure is used to treat only the early stages of inflammatory arthritis.  This procedure may be able to be performed by hip arthroscopy.
3. Core Decompression – This is indicated for early avascular necrosis, particularly in patients with SLE.  The aim is to reduce pressure in the bone marrow and encourage blood flow to the at risk (necrotic) avascular area.  It may be combined with a bone graft procedure.

The various surgical options specific to your situation will be discussed with you. It is important to ask why a specific procedure is being recommended and what outcomes may be expected.  Complications are possible in any surgery, and A/Prof Woodgate will inform you of possible issues in your situation, and undertake the necessary steps to minimize the risks.