What types of arthritic conditions are associated with hip arthropathy?

Arthritic Conditions Associated with Hip Arthropathy

Rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis (AS) and psoriatic arthritis (PsA), juvenile idiopathic arthritis (JIA), and systemic lupus erythematosus (SLE) are the primary arthritic conditions associated with hip arthropathy. 1

Primary Inflammatory Arthritides Affecting the Hip

Rheumatoid Arthritis

• Commonly affects the hip joint, leading to significant pain and functional limitations
• Characterized by symmetric polyarticular involvement
• Hip involvement can progress to rapidly destructive arthropathy in some cases 2
• Risk factors for rapidly destructive hip arthropathy in RA include:
  • Older age at diagnosis
  • RA onset after age 40
  • Severe RA affecting multiple major joints
  • Long-term steroid and DMARD use
  • Low body mass index (<20 kg/m²) 2
• Patients with RA have worse outcomes after total hip replacement compared to those with osteoarthritis, with higher rates of poor function and pain even with modern disease-modifying therapies 3

Spondyloarthritis

1. Ankylosing Spondylitis

   • Hip involvement occurs in up to 80% of patients 1
   • Characterized by inflammatory back pain, sacroiliitis, and progressive spinal fusion
   • Strong association with HLA-B27 genetic marker 1, 4
   • Hip arthropathy can lead to significant disability and often requires total hip arthroplasty

2. Psoriatic Arthritis

   • Hip joint involvement occurs in approximately 6.3% of PsA patients 5
   • Risk factors for hip involvement include:
     • Earlier onset of arthritis
     • Presence of psoriatic spondylitis (81% of PsA patients with hip involvement also have spondylitis) 5
   • Often progresses rapidly, with 50% of patients requiring hip arthroplasty within 5 years of symptom onset 5
   • Bilateral hip involvement is common

3. IBD-Associated Arthropathy

   • Classified into two main types:
     • Type I (pauciarticular): Affects fewer than 5 large joints, including the hip; correlates with IBD flares 1, 6
     • Type II (polyarticular): Affects more than 5 joints; runs independently of IBD activity 1, 6
   • Hip involvement is more common in the axial form of IBD-associated arthropathy

Juvenile Idiopathic Arthritis

• Can affect the hip joint, particularly in polyarticular and systemic subtypes
• Hip involvement may lead to growth disturbances and early degenerative changes
• Often requires aggressive management to prevent long-term disability 1

Systemic Lupus Erythematosus

• Hip involvement is less common than in other inflammatory arthritides
• When present, can range from mild synovitis to avascular necrosis
• Avascular necrosis of the hip is a significant concern, particularly in patients on long-term corticosteroid therapy 1

Diagnosis and Assessment

Clinical Features

• Pain in the groin, buttock, or referred to the knee
• Limited range of motion, particularly internal rotation
• Morning stiffness lasting more than 30 minutes
• Functional limitations with walking and daily activities

Imaging

• Plain radiographs: May show joint space narrowing, marginal erosions, and osteophyte formation
• MRI: Gold standard for early detection of inflammatory changes and bone marrow edema
• Ultrasound: Useful for detecting synovitis and effusion

Management Considerations

Medical Management

• Disease-modifying antirheumatic drugs (DMARDs) for underlying inflammatory condition
• Biologic agents (TNF inhibitors, IL-6 inhibitors) for refractory disease
• Perioperative management of immunosuppressive medications is crucial when surgical intervention is needed 1

Surgical Management

• Total hip arthroplasty (THA) is often required for advanced hip arthropathy
• Patients with inflammatory arthritis have higher risks of perioperative complications, including infection 1
• Special perioperative considerations include:
  • Continuation of conventional DMARDs throughout the perioperative period
  • Withholding biologic agents for one dosing cycle prior to surgery
  • Restarting biologics after evidence of wound healing (typically 14 days) 1
  • Maintaining current glucocorticoid dosing rather than "stress dosing" 1

Clinical Pearls and Pitfalls

• Early diagnosis and aggressive treatment of inflammatory arthritis can help prevent or delay hip joint damage
• Hip involvement in inflammatory arthritis often indicates more severe disease and worse prognosis
• Patients with inflammatory arthritis undergoing THA have higher risks of complications and worse outcomes compared to those with osteoarthritis 3
• Regular monitoring of hip joint status in patients with inflammatory arthritis is essential, particularly those with risk factors for hip involvement

By understanding the specific arthritic conditions associated with hip arthropathy, clinicians can better anticipate, diagnose, and manage these challenging cases to optimize patient outcomes and quality of life.