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The term “arthritis” literally means inflammation of a joint, but is generally used to describe any condition in which there is damage to the cartilage. Inflammation, if present, is in the synovium. The proportion of cartilage damage and synovial inflammation varies with the type and stage of arthritis. Usually the pain early on is due to inflammation. In the later stages, when the cartilage is worn away, most of the pain comes from the mechanical friction of raw bones rubbing on each other.
An X-Ray and Illustration Showing an Arthritic Hip Joint (opposite).
Osteoarthritis mainly damages the joint cartilage, but there is often some inflammation as well. It usually affects only one or two major joints (usually in the legs). It does not affect the internal organs. The cause of hip osteoarthritis is not known. It is thought to be simply a process of “wear and tear” in most cases. Some conditions may predispose the hip to osteoarthritis, for example, a previous fracture that involved the joint. Growth abnormalities of the hip (such as a shallow socket) may lead to premature arthritis. Some childhood hip problems later cause hip arthritis (for example, a type of childhood hip fracture known as a Slipped Epiphysis; also Legg-Perthe’s Disease). In osteoarthritis of the hip the cartilage cushion is either thinner than normal (leaving bare spots on the bone), or completely absent. Bare bone on the head of the femur grinding against the bone of the pelvic socket causes mechanical pain. Fragments of cartilage floating in the joint may cause inflammation in the joint lining, and this is a second source of pain. X-rays show the “joint space” to be narrowed and irregular in outline.
There is no blood test for osteoarthritis.
Rheumatoid Arthritis (R.A.) starts in the synovium and is mainly “inflammatory”. The cause is not known. It eventually destroys the joint cartilage. Bone next to the cartilage is also damaged; it becomes very soft (frequently making the use of an uncemented implant impossible). R.A. affects multiple joints simultaneously. It also affects internal organs. Another form of hip arthritis that is mainly “inflammatory” is Lupus. There are other more rare forms of arthritis that are also mainly “inflammatory”. They are basically similar to R.A.. X-ray changes in R.A. are essentially similar to osteoarthritis plus a loss of bone density.
Blood tests for rheumatoid arthritis are not very accurate. “Rheumatoid Factor” is present in the blood in about 80% of patients who have had rheumatoid arthritis for more than 18 months. Early on in the disease the percentage is much lower. Unfortunately, about 7% of people over the age of 70 test positive for rheumatoid factor, even though they do not have rheumatoid arthritis. The test, by itself, is therefore not very reliable.
Anti-inflammatory medications (see Non-Steroidal Anti-Inflammatory Drugs) are effective in treating the “inflammatory” aspect of either rheumatoid or osteoarthritis.
Osteonecrosis (literally: “dead bone”) is another serious cause of hip pain. It is not “arthritis”. It is a painful condition in which part of the femoral head dies. This dead bone cannot stand up to the stresses of walking, the femoral head collapses, and becomes irregular in shape. With collapse the joint becomes even more painful. The most common known causes of osteonecrosis are excessive alcohol use and excessive use of cortisone-containing medications. In most cases the cause is “idiopathic”, i.e. unknown.
SYMPTOMS OF HIP DISEASE
The most prominent symptom of hip arthritis is pain. Most patients think that their hip is in the region of the buttocks and are surprised to learn that true hip pain is most commonly experienced in the groin. Groin pain of hip arthritis is sometimes misdiagnosed at first as a hernia or a “groin pull”. (There is no known medical diagnosis of, and no Wikipedia definition for “groin pull”, but strangely, patients frequently self-diagnose themselves with this “condition”). The pain can radiate down the front of the thigh for a few inches as well. Occasionally it goes all the way down the thigh to the knee (“referred pain”). This is because the hip and knee have an overlapping nerve supply. In fact, in some patients with hip disease, knee pain may be the only symptom!
Back pain is even more frequently confused with hip pain. Pain in the buttocks, across the low back and down the back of the thigh usually comes from the spine. It usually indicates a pinched nerve in the lower spine. Patients with a pinched nerve will also often have numbness or tingling in the leg. To complicate matters, some patients with an arthritic hip may also have a pinched nerve from a back disorder.
It is important in such cases to determine which problem is causing most of the pain: the hip or the back. If your problem is mainly in your back, you may still be left with most of your pain after going through a hip replacement, and you will not be very happy with the result! If most of your pain is from the hip, a hip replacement may have the added benefit of improving your back condition as well, since the stiffness of an arthritic hip can aggravate a back problem.
Most patients with significant hip disease have a limp and one leg may feel shorter than the other (see true and false leg lengths). Bone-on-bone contact occasionally causes the patient to feel or hear the hip creaking during walking. As the disease progresses, the hip becomes stiff and less movement is possible. This may make it difficult for you to clip your toe nails or to tie your shoe laces, and may also limit your ability to spread your legs. Quite often the first step or two after prolonged sitting may be especially painful. Eventually you may have to “take a break” to ease the pain after walking only short distances. The distance you can walk will gradually decrease until you can only take one or two steps at a time. The three common causes of pain around the hip are arthritis, bursitis, or a pinched nerve in the lower back (the commonest cause). The groin pain of hip arthritis is sometimes misdiagnosed at first as a hernia.
TREATING HIP ARTHRITIS WITHOUT SURGERY
Should you limit your activities? If you have hip arthritis, the more you walk the more the hip will hurt. In time, running, tennis, golf and eventually even walking may become impossible. You can minimize the pain by simply cutting back on activities which seem to aggravate the hip. Whenever possible, use an elevator (or an escalator) instead of stairs, and avoid long walks that leave you in pain. However, “saving the joint” by becoming totally sedentary will not slow down the arthritis. Therefore it is recommended that you remain as active as your pain will comfortably allow. A reported study in the Annals of Internal Medicine, in 1992 suggests that people with hip arthritis who force themselves to remain active may do better in the long run than those who “baby” themselves. Also, being totally sedentary leads to a loss of muscle and bone strength. If you feel that you really need it, ask Dr. Huddleston’s staff to arrange for a handicapped parking sign for your car, but you are better off parking further away and forcing yourself to walk!
The best all-around exercise for you is swimming. The water relieves the stress on your hip as you “walk” about in the shallow end of the pool. Dr. Huddleston can prescribe a program of “pool therapy” for you. Bicycling (stationary or mobile) is also well tolerated. If you do not have access to an exercise bike or pool, then walk as much as you can tolerate without causing yourself excessive pain.
A cane has been known since pre-biblical times to be an effective pain-reliever for hip arthritis. Unfortunately most people today are too vain to use one! Two important facts about canes: 1). Hold the cane in the opposite hand (yes, the opposite hand) from the side with the hip problem and 2). The cane should be the correct height. Any medical supply company that sells you a cane will adjust it to the correct length.
Weight loss will probably decrease your pain if you are greatly overweight. One pound of weight loss equals 3 pounds in stress reduction on the hip during normal gait! But weight reduction alone is unlikely to completely relieve the pain. Obesity also makes the hip operation more difficult, and complications occur more frequently in overweight people. It can be very difficult to lose weight when you are not very active because of your hip pain. Do the best you can!
Gold injections and methotrexate may be useful in rheumatoid arthritis. The treatment is complex and usually only given under the supervision of a rheumatologist.
Cortisone injection into the hip joint can be very effective if the cortisone is injected accurately into the joint. It quite frequently gives good relief for six months or so. It is a deep joint, and a long needle must be used with x-ray guidance for the needle. It is therefore not often done as an office procedure. Dr. Huddleston is quite expert at injecting the hip in the office without x-rays because of his intimate knowledge of the anatomy of the hip. In obese patients he recommends the use of x-rays to be sure the needle is in the joint. Cortisone occasionally gives remarkable results, with even up to a year of relief in quite severe arthritis. You never how well it will work until you actually try it. Bursitis of the hip (another common cause of “hip pain”) is easily (and effectively) treated with cortisone injections given in the office.
Non-Steroidal Anti-Inflammatory Drugs
Non-Steroidal Anti-Inflammatory Drugs NSAIDs (Pronounced EN-seds), are a group of drugs which decrease the inflammation (pain and swelling) in arthritic joints. The pain relief from NSAIDs can be quite amazing. Although they are commonly referred to as “arthritis pills”, none of them will in any way influence the outcome of the arthritis. There are many NSAIDs available, and newer ones are constantly being brought onto the market. The “newest” one is not necessarily the most effective. Most people respond better to one NSAID than to another, and you may have to try several before the “right” one can be found for you. They all have potentially serious side effects and should only be taken under medical supervision. Most can only be obtained by prescription and are expensive. Aspirin (which is also an NSAID!) is cheap, and is often just as effective as any of the other NSAIDs. It should therefore be tried first. If even coated aspirin (Ecotrin) affects your stomach, then try extra-strength Tylenol. Most NSAIDs are “COX I Inhibitors.”
Always take NSAIDs with food or antacids, or with a full glass of water. These medications have potentially serious side effects, and should only be taken under close medical supervision.
COX II Inhibitors are a fairly new class of NSAIDS which include Celebrex and Mobic. (Vioxx and Bextra have been taken off the market).
In general, these drugs have been found to be slightly more effective than most (but not all) of the older, COX I NSAIDs, but this is not true for all patients. They have much fewer gastric side effects than COX I inhibitors, but side-effects are not eliminated. Celebrex cannot be taken by people allergic to sulfa and can elevate blood pressure if you already have hypertension by counteracting the effectiveness of some blood pressure medications known as “ACE Inhibitors”.
Side Effects of NSAIDs
About 30% of patients on NSAIDs can expect some side effects. Most side effects are mild and may go away without treatment. Others are more serious and should be treated right away.Most NSAIDs can affect the liver, bone marrow or kidneys (see Table below). Although Dr. Huddleston may give you the initial prescription for NSAIDs, and help you find the most effective one for you, we prefer your family doctor or internist to continue prescribing the medication, since blood tests are needed at least every three months to determine if you are having harmful side effects. The damage is reversible if the medication is stopped in time.
Stomach Problems: Stop the medication immediately if you get stomach pain, cramping or burning. Check with your doctor if you get nausea, constipation or diarrhea which lasts for more than three days.
Fluid Retention: This may happen if the NSAIDs affect your kidney function. You may notice swelling of the ankles, feet, or lower legs, or an unusual weight gain. If this continues for more than two weeks, check with your doctor.
Bruising Tendency: NSAIDs interfere with the clotting of blood and may cause you to bruise easily. If you have any bleeding problems or take blood thinners, check with your doctor before taking NSAIDs.
Dizziness, Lightheadedness, or Drowsiness: These are rare. If they do occur they usually go away when your body adjusts to the medicine.
Stomach Ulcers: Some people taking NSAIDs develop stomach ulcers, and occasionally these may bleed. The bleeding can come with very little warning, and can even be severe enough to cause death. This is why stomach symptoms should be taken very seriously in patients on NSAIDs.If you have severe heartburn, or if your stools turn pitch black (altered blood), or if you vomit blood or material that looks like coffee grounds, stop the medicine and call your doctor immediately.
Note that iron pills (taken for anemia or during the period you are giving blood for auto transfusion) will also turn your stools pitch black.
Most people can take NSAIDs without having stomach problems. However, you may have a higher risk if you have had previous ulcers, or are over the age of 60, use cortisone (such as Prednisone), smoke or drink alcohol. If you are in any of these high risk categories, it is recommended that you take Cytotec (which helps to protect the stomach) in addition to the NSAID. Cytotec is not routinely prescribed as it is expensive and has side effects of its own. There are other medications which can help protect the stomach.
Drugs that may interact with NSAIDs
Some drugs may interact adversely with NSAIDs. In some cases the combination should be avoided completely; in others, the dosage of either drug may need compensatory adjustment.Never take Aspirin-containing medication at the same time as taking NSAIDs.
If you are taking any of the following drugs, consult your internist before commencing treatment with NSAIDs. There may be others not included in this list: aspirin, lithium, phenytoin, methotrexate, digoxin, probenecid, barbiturates, anticoagulants, high blood pressure medications, antacids, oral diabetes medications or diuretics.
Allergy to the NSAIDs: This may be manifested as rapid breathing, gasping, wheezing, fainting, hives, itching, skin rash, rapid heart beat, or sudden puffiness of the eyelids. Allergy is exceedingly rare. It occurs sometimes in people who are truly allergic to aspirin. If you have these symptoms and you do not have someone to drive you to the hospital, call an ambulance and get to the hospital as soon as you can, since the allergic reaction could be severe and need urgent medical treatment.Remember to discontinue the use of any aspirin or aspirin-containing drugs 7 days prior to your surgery. All nonsteroidal anti-inflammatory medications should be discontinued 7 days prior to your surgery.
The reason for discontinuing these medications is that they can increase bleeding at the time of surgery. Tylenol, Darvocet, and Tylenol with Codeine can be taken by mouth up to the night before the operation. If you have an uncemented implant, you should not use Indomethacin after surgery unless approved by Dr. Huddleston, since it may interfere with bone-ingrowth into the implant surface.
EXAMPLES OF PRESCRIPTION AND OVER-THE-COUNTER NSAIDs
|Generic Name||Some Brand Names|
|COX I INHIBITORS|
|Anacin, Bayer, BC Powder, Bufferin
Excedrin, Ecotrin, Zorpin
|non-aspirin salicylates||Arthropan, Disalcid, Magan, Trilisate|
|ibuprofen||Advil, Medipren, Motrin
Nuprin, Rufen *
|naproxen sodium||Anaprox *|
|COX II INHIBITORS|
|Celecoxib||Celebrex * +|
* Can affect liver or kidneys. Need to have blood tests every 3-6 months (Complete Blood Count, Liver Function Tests, serum creatinine).
+ Can elevate blood pressure.
RULES FOR PATIENTS TAKING NSAIDs
- Tell your doctor if you are taking any other prescription or over-the-counter medications. Also if you have any other medical problems, especially stomach ulcers, bleeding tendency, colitis, diverticulitis (or other stomach or bowel disease), kidney disease, asthma or liver disease.
- Always take NSAIDs with a meal and plenty of liquids.
- Don’t exceed the dose prescribed by your doctor if it doesn’t seem to be working to your satisfaction. There is a maximum effective dose for each NSAID and it could be very harmful to exceed that dose.
- Don’t take NSAIDs only when you have pain or only when you expect to have pain (such as before a game of golf). NSAIDs may take up to two weeks to reach their full effect.
- Don’t take NSAIDs with alcohol or caffeine-containing beverages. These beverages make stomach problems worse.
- Don’t simultaneously take other medications containing aspirin compounds or ibuprofen. Taking the prescribed NSAID in addition may cause side-effects from to much NSAID in your BODY onunload=”leave()” . You can take Tylenol together with any of the NSAIDs.
- Don’t drive or operate machinery if your NSAID makes you feel drowsy or dizzy.
Pain Medications: Eventually NSAIDs will not give you adequate relief. If for some reason you are not able to undergo hip surgery by that time, then your only recourse is to take pain medications, starting with over-the-counter medications such as Tylenol, and progressing to stronger prescription medications from your doctor as necessary.
Commonly prescribed pain medications:
|Pain Medicine||Generic or Other Names||Comments|
|Aspirin compounds||Anacin, Bayer, Bufferin, Easprin,
Excedrin, Ecotrin, Zorpin
|Codeine||A, Rx, ***|
|Darvocet||Propoxyphene with Tylenol||H, Rx, ***|
|Darvon||Propoxyphene||H, Rx, ***|
|Aspirin and Codeine||A, Rx, ASA, ***|
|Fioricet||Butalbital with Tylenol||H, Rx, ***|
|Fiorinal||Butalbital with Aspirin||H, Rx, ASA, ***|
|Norco||Hydrocodone + Tylenol||H, Rx, ***|
|Oxycontin||Oxycocodone||A, Rx, ****|
|Percodan||Oxycodone, Oxycodan||A, Rx, ASA, ****|
|Percocet||Oxycodone with Tylenol||A, Rx, ****|
|Talacen||Pentazocine + Aspirin||H, Rx, ASA, ***|
|Vicodin||Hydrocodone + Tylenol||H, Rx, ****|
|Legend to Comments
Glucosamine Sulfate/Chondroitin Sulfate (“chondroprotective agents or nutraceuticals”) are in widespread use for the treatment of arthritis. There is some scientific evidence that they may slow the arthritic process (Journal of Arthroplasty, April 2003), and that they have a pain-relieving, NSAID-effect without the side-effects of NSAIDS (Journal of the American Academy of Orthopaedic Surgeons, March 2001). The dose is 1500 mg of Glucosamine plus 1200 mg of Chondroitin taken once a day. They give the best results when taken together. SAM-e, MSM and CMO are other neutraceuticals widely used even though there is less evidence for their efficacy.
Hyalgan, Synvisc and Supartsz (“viscosupplementation”) are clear liquids purified from rooster combs. They increase the viscosity of joint fluid and the elasticity of the joint cartilage, and are also thought to have a weak NSAID (pain-relieving) effect. It only stays in the joint for about 48 hours, but the improvement can last for six to 12 months. It works best on mild to moderate arthritis. Repeat courses can be given every 6 to 12 months if it works well. FDA approval is only for use in the knee, but it can be used “off label” in the hip joint. A series of three or five injections are given into the joint. You cannot have these injections if you are allergic to eggs or feathers. Synvisc sometimes causes severe inflammation and swelling in the knee. Dr. Huddleston prefers Hyalgin because the side effects are negligible.
Cartilage transplantation has only been approved for use in the knee, in people under 45, with a small circumscribed area of arthritis. Cartilage cells are removed from the knee, grown in the lab, then transplanted surgically to the affected area. It has not been used in the hip yet, even experimentally, but the future holds promise.
KEEPING FIT WITH AN ARTHRITIC HIP
A recent study suggests that people with hip arthritis may fare better if they force themselves to remain as active as possible, even if the exercise causes some pain. Take pain medicine as necessary before exercising. There is no evidence that being active will cause a more rapid deterioration of your arthritic hip. Being active is important for your general health and mental well-being. It also keeps your muscles strong, and this will speed your recovery after surgery. You are the best judge of what you can do. Remain as active as your pain will allow you to be until you decide to proceed with surgery.
Walking a treadmill or jogging will usually aggravate hip pain. The best all-around exercise for you is swimming. The water relieves the stress on your hip as you “walk” about in the shallow end of the pool. Lap swimming is excellent – it involves the use of most of your body muscles. Dr. Huddleston can prescribe a program of “pool therapy” for you if it is available in your area. Bicycling (stationary or mobile) is also well tolerated. If you do not have access to an exercise bike or pool, then walk as much as you can tolerate without causing yourself excessive pain.
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