Can a patient with calcium pyrophosphate dihydrate (CPPD) arthropathy of the hip be referred to orthopedics?

Orthopedic Referral for CPPD Arthropathy of the Hip

Yes, refer patients with CPPD arthropathy of the hip to orthopedics when they have refractory pain or disability with radiographic evidence of structural damage, as total hip arthroplasty should be considered independent of age. 1

When to Refer to Orthopedics

Absolute Indications for Referral

• Refractory pain or disability despite optimal medical management (NSAIDs, colchicine, intra-articular corticosteroids, and second-line agents like methotrexate or hydroxychloroquine) combined with radiographic evidence of structural joint damage 1

• Severe structural damage on imaging that limits function, as CPPD can cause destructive arthropathy similar to osteoarthritis, and total hip arthroplasty outcomes are comparable to standard OA 1, 2

• Failure of conservative management after 6-8 weeks of structured treatment including NSAIDs with gastroprotection, low-dose colchicine (0.5-1.0 mg daily), and physical therapy 2, 3

Clinical Context for Referral Decision

The hip is a common site for acute CPP crystal arthritis (pseudogout), and when CPPD affects the hip, it can present as severe monoarticular inflammation mimicking septic arthritis or as chronic destructive arthropathy 4, 5. The key distinction is whether the patient has:

• Osteoarthritis with CPPD: Manage identically to standard OA following evidence-based guidelines, with the same indications for arthroplasty referral as OA without CPPD 2, 1

• Chronic CPP inflammatory arthritis: Attempt medical management first with NSAIDs, colchicine, and second-line agents (hydroxychloroquine, methotrexate), but refer if erosive changes or structural damage develop despite treatment 3, 1

Medical Management Before Referral

First-Line Treatment to Attempt

• Joint aspiration with intra-articular corticosteroid injection for acute flares, which is optimal first-line treatment and often sufficient alone 2, 1

• Oral NSAIDs with gastroprotection for chronic symptoms, as older patients with CPPD require gastroprotective agents 2, 3

• Low-dose colchicine (0.5-1.0 mg daily) for prevention of recurrent flares or as first-line for chronic inflammatory arthritis 2, 3

Second-Line Options for Refractory Cases

• Methotrexate (5-10 mg/week) for patients resistant to first-line treatments, with demonstrated efficacy in reducing pain intensity and joint swelling 3, 1

• Hydroxychloroquine as the preferred second-line agent for chronic CPP inflammatory arthritis, with NNT of 2 for clinical response 2, 3

Critical Pitfalls to Avoid

• Do not delay referral in patients with significant structural damage and functional impairment, as age alone is not a contraindication to total hip arthroplasty in CPPD 1

• Avoid intra-articular high molecular weight hyaluronan in CPPD patients, as it may induce acute attacks and is specifically contraindicated 2, 3

• Never use intravenous colchicine due to serious toxicity risk, and avoid traditional high-dose colchicine regimens due to marked side effects 2

• Always provide gastroprotection with NSAIDs in older patients, as CPPD predominantly affects this population with higher GI bleeding risk 3, 2

Practical Algorithm

1. Confirm diagnosis with joint aspiration showing positively birefringent CPP crystals and radiographic chondrocalcinosis 5, 6

2. Initiate medical management with NSAIDs/gastroprotection plus colchicine, and consider intra-articular corticosteroids for acute flares 2, 3

3. Reassess at 6-8 weeks: If no improvement or progressive structural damage on imaging, proceed with orthopedic referral 7

4. Refer immediately if patient presents with severe disability, inability to bear weight, or radiographic evidence of advanced joint destruction 1