What are the treatment options for osteoarthritis (OA) of the hip?

Treatment Options for Osteoarthritis of the Hip

The management of hip osteoarthritis requires a combination of non-pharmacological and pharmacological interventions, with total hip replacement reserved for patients with refractory pain and disability. 1

Non-Pharmacological Treatments

• Education and Self-Management Programs: Regular education about the condition and self-management strategies should be provided to all patients with hip OA 1

• Exercise Therapy:

  • Land-based cardiovascular and/or resistance exercise is strongly recommended 1
  • Aquatic exercise is also strongly recommended 1
  • Exercise should be supervised by a physical therapist in combination with manual therapy 1
  • After total hip arthroplasty (THA), either formal physical therapy or unsupervised home exercise is recommended based on high-quality evidence 1

• Weight Management: Weight loss is strongly recommended for overweight or obese patients 1

• Assistive Devices: Walking aids (canes, walkers) should be provided as needed 1

• Thermal Agents: Local heat or cold applications can be used for symptomatic relief 1

• Psychosocial Interventions: These should be incorporated into management plans to address mood disorders, stress, and coping skills that often accompany chronic pain conditions 1

Pharmacological Treatments

First-Line

• Acetaminophen (Paracetamol): Up to 4g/day is recommended as the first-line oral analgesic for mild to moderate pain due to its efficacy and safety profile 1

Second-Line

• NSAIDs: Should be added or substituted when acetaminophen provides inadequate response 1

  • Use the lowest effective dose for the shortest possible period 1
  • For patients with increased gastrointestinal risk, use either:
    • Non-selective NSAIDs plus a gastroprotective agent (proton pump inhibitor)
    • Selective COX-2 inhibitors 1

• Topical NSAIDs: Consider before oral NSAIDs, particularly for patients with comorbidities 1

Third-Line

• Opioid Analgesics: Useful alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 1

  • Tramadol is conditionally recommended 1
  • Strong opioids should be reserved for patients with refractory pain who are not candidates for surgery 1

• Intra-articular Corticosteroid Injections: May be considered for patients with flares unresponsive to analgesics and NSAIDs 1

  • Should be guided by ultrasound or x-ray 1
  • Provide short-term pain relief 2

• Duloxetine: May be considered for pain management in OA, though evidence specific to hip OA is limited 3

Not Recommended Treatments

• Glucosamine and Chondroitin: Not recommended based on current guidelines 1
• Intra-articular Hyaluronic Acid (Viscosupplementation): Evidence does not support use in hip OA 1, 4
• Typical Opioids: Most guidelines recommend against long-term use 4
• Electroacupuncture: Not recommended 1

Surgical Interventions

• Joint-Preserving Procedures: Osteotomy should be considered in young adults with symptomatic hip OA, especially with dysplasia or varus/valgus deformity 1

• Total Hip Replacement: Should be considered in patients with radiographic evidence of hip OA who have refractory pain and disability despite conservative management 1

  • For elderly patients with poor bone quality, cemented femoral fixation should be considered to reduce periprosthetic fracture risk 1

Treatment Algorithm

1. Initial Management:

   • Patient education and self-management strategies
   • Exercise program (land-based and/or aquatic)
   • Weight loss if overweight
   • Acetaminophen for pain control

2. If Inadequate Response:

   • Add or substitute NSAIDs (topical or oral with appropriate gastroprotection)
   • Consider thermal agents and assistive devices

3. For Persistent Symptoms:

   • Consider intra-articular corticosteroid injections for flares
   • Consider tramadol or duloxetine
   • Evaluate for surgical candidacy

4. For Refractory Cases:

   • Joint-preserving surgery in younger patients with appropriate indications
   • Total hip replacement for patients with significant pain and functional limitation

Common Pitfalls and Caveats

• Overreliance on Medications: Non-pharmacological approaches should always be incorporated into treatment plans 1, 5

• Inadequate Pain Control: Pain that significantly limits function should be addressed promptly to prevent deconditioning and further functional decline 1

• Ignoring Comorbidities: Treatment selection must consider cardiovascular, gastrointestinal, and renal risks, particularly when prescribing NSAIDs 1

• Delayed Referral for Surgery: Patients with persistent pain and disability despite conservative management should be evaluated for surgical intervention 1

• Underutilization of Education: Patient education has been shown to be effective in reducing pain and improving function in hip OA and should be emphasized 5