What are the treatment options for arthritis of the hips?

Treatment Options for Arthritis of the Hips

The optimal management of hip arthritis requires a combination of non-pharmacological and pharmacological interventions, with total hip arthroplasty strongly recommended for patients with advanced hip arthritis who have refractory pain and disability despite conservative management. 1, 2

Non-Pharmacological Treatments

• Exercise therapy is strongly recommended for all patients with hip arthritis, including land-based cardiovascular/resistance exercises and aquatic exercise, preferably supervised by a physical therapist 1, 2, 3
• Education and self-management programs should be incorporated into treatment plans to help patients understand their condition and develop coping strategies 2, 3
• Weight loss is strongly recommended for overweight or obese patients with hip arthritis to reduce joint stress 2, 3
• Walking aids such as canes should be provided as needed to improve mobility and reduce joint loading 2, 3
• Local heat or cold applications can provide symptomatic relief 2
• Psychosocial interventions should address mood disorders, stress, and coping skills that often accompany chronic pain conditions 2

Pharmacological Treatments

• Acetaminophen (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, 2
• NSAIDs should be added or substituted when acetaminophen provides inadequate response, using the lowest effective dose for the shortest possible period 1, 2, 4
• Topical NSAIDs should be considered before oral NSAIDs, particularly for patients with comorbidities 2, 5
• Opioid analgesics (such as tramadol) may be useful alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 1, 2
• Intra-articular corticosteroid injections (guided by ultrasound or x-ray) may be considered for patients with flares unresponsive to analgesics and NSAIDs 1, 2

Surgical Interventions

• Total hip arthroplasty is strongly recommended for patients with advanced hip arthritis who have refractory pain and disability despite conservative management 1, 2
• Joint-preserving procedures such as osteotomy should be considered in young adults with symptomatic hip arthritis, especially in the presence of dysplasia or varus/valgus deformity 1, 2
• The surgery should be performed by orthopedic surgeons and at hospitals that are highly experienced in joint replacement in patients with arthritis 1

Treatment Algorithm

1. First-line approach:

   • Education and self-management strategies 2, 3
   • Exercise therapy (land-based and/or aquatic) 1, 2, 3
   • Weight loss if overweight/obese 2, 3
   • Walking aids as needed 2, 3
   • Acetaminophen for pain control (up to 4g/day) 1, 2

2. If inadequate response:

   • Add topical NSAIDs 2, 5
   • Progress to oral NSAIDs at lowest effective dose 1, 2, 4
   • Consider intra-articular corticosteroid injections for flares 1, 2

3. For persistent symptoms:

   • Consider opioid analgesics (e.g., tramadol) when other options fail 1, 2
   • Evaluate for surgical intervention 1, 2

4. Surgical options:

   • For young adults: Consider joint-preserving procedures 1, 2
   • For advanced arthritis with refractory symptoms: Total hip arthroplasty 1, 2

Not Recommended Treatments

• Glucosamine and chondroitin are not recommended for hip arthritis 2
• Intra-articular hyaluronic acid (viscosupplementation) is not recommended due to lack of supporting evidence 2, 5
• Electroacupuncture is not recommended 2
• Spinal manipulation with high-velocity thrusts is strongly recommended against in patients with ankylosing spondylitis who have spinal fusion or advanced spinal osteoporosis 1

Common Pitfalls and Caveats

• Many patients with hip arthritis do not receive appropriate non-pharmacological treatments; only 28% of patients are prescribed physiotherapy before progressing to total hip replacement 6
• NSAIDs should be used with caution, especially in elderly patients or those with cardiovascular, renal, or gastrointestinal risk factors 2, 4
• Delaying appropriate surgical intervention when conservative measures fail can lead to unnecessary prolonged pain and disability 1
• The effectiveness of combined therapies remains unclear and requires further investigation 7