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EBMG

Osteoarthritis of the Hip and Knee

See also the article Osteoarthritis of the hand and wrist Osteoarthritis of the Hand and Wrist and osteoarthritis of the ankle and the foot in the article Painful conditions of the ankle and foot in adults Painful Conditions of the Ankle and Foot in Adults.

Essentials

Exercise therapy and avoidance of overweight prevent the development of osteoarthritis of the hip and knee and reduce the pain and functional impairment caused by it.
The efficacy of oral and intra-articular pharmacotherapy for reducing the symptoms of osteoarthritis is uncertain.
Pharmacotherapy can be used to alleviate the pain caused by osteoarthritis, but long-term pharmacotherapy is associated with adverse effects.
Surgical treatment can be used if pain is otherwise unmanageable or if osteoarthritis impairs the patient's functional ability significantly.

Epidemiology and aetiology

Osteoarthritis of the hip
- Virtually not encountered in persons less than 45 years of age but the prevalence increases especially in the age group of 65-74 years. About one fifth of both men and women aged 75-84 years have hip osteoarthritis.
- Known risk factors include age, overweight, injuries, joint loading, developmental disorders of the joint as well as genetic factors.
Osteoarthritis of the knee
- Virtually not encountered in persons less than 45 years of age. Prevalence increases especially in the age group of 55-64 years in men and in the age group of 65-74 years in women. In the age group of 75-84 years, 16% of men and about one third of women have knee osteoarthritis.
- Risk factors, in addition to those for hip osteoarthritis, include female gender, history of menisceal injury or meniscectomy and deformities of the knee.

Symptoms

Initially pain during activity that increasingly limits the ability to move. Later pain at rest begins to disturb sleep.
Stiffness of the joint, decreased functional ability
As osteoarthritis progresses, malposition often develops, aggravating the condition. Swelling may develop in the joint.

Clinical examination

See Clinical Examination of Patients with Joint Inflammation in Primary Health Care.
Inspection of the joint
- Deformity
- Varus-valgus malalignment
- Swelling
Mobility of the patient
- Walking, limp
- Crouching
Manual examination
- Hip joint: passive abduction and adduction, inward and outward rotation, flexion and extension. Inward rotation is the first motion to become restricted.
- In knee osteoarthritis, both extension and flexion deficits develop.
- The WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) http://www.womac.com/ questionnaire may be used in the assessment of functional ability.
Laboratory tests
- Not routinely needed but may be necessary for differential diagnostics
- Depending on the situation: basic blood count with platelet count, CRP, ESR, rheumatoid factor, CCP (citrulline antibodies), urate
Radiological investigations
- The need for plain x-rays is considered: would the finding affect the treatment provided?
- Repeted imaging should be avoided unless the clinical situation changes essentially.
- The posteroanterior (PA) view of the knees should be obtained with the patient standing with the knees slightly flexed. Both knees should be positioned in the same picture. The lateral view is obtained whith the patient either standing or recumbent.
- X-rays of the hips are taken in the anteroposterior (AP) direction with the patient either standing or recumbent. The image quality is better especially in obese patients if the patient is in recumbent position.
- MRI is not indicated as a first-line investigation in osteoarthritis. If x-rays raise the suspicion of avascular necrosis, malignancy or infection, MRI is recommended.

Non-pharmacological management Electromagnetic Fields for the Treatment of Osteoarthritis, Interventions to Improve Adherence to Exercise for Chronic Musculoskeletal Pain in Adults

Dietary modification combined with self-directed exercise are recommended to overweight patients with osteoarthritis.
Exercise consists of general physical conditioning by e.g. walking, cycling, swimming and other types of water exercise Aquatic Exercise for the Treatment of Knee and Hip Osteoarthritis, as well as exercises that improve mobility and muscle strength of the knees and hips. The recommended forms of exercise involve neither forceful jolts nor excessive compressing or twisting movements directed at the joints. It is not known how the intensity of the exercise affects the results of treatment High-Intensity Versus Low-Intensity Physical Activity or Exercise in People with Hip or Knee Osteoarthritis.
Various types of adjustment training programmes have not been found to relieve symptoms compared with conventional treatment Self-Management Education Programmes for Osteoarthritis.
Physical therapies, cryotherapy Thermotherapy for Treatment of Osteoarthritis, transcutaneous electrical nerve stimulation (TENS) Transcutaneous Electrical Nerve Stimulation for Knee Osteoarthritis, acupuncture Acupuncture as a Symptomatic Treatment for Osteoarthritis or balneotherapy Balneotherapy for Osteoarthritis can be used.
knee braces and shoe support, heel wedges
The use of assistive devices aims at alleviating the patient's symptoms and improving functional ability (e.g. a walking stick, crutches, a wheeled walking frame, aids for putting on cloths, toilet support rails).

Pharmacotherapy Doxycycline for Osteoarthritis of the Knee or Hip, S-Adenosylmethionine for Osteoarthritis of the Knee or Hip

Pharmacotherapy should be used neither as the sole nor as the primary treatment in osteoarthritis.

Analgesics

In long-term use, paracetamol has fewer adverse effects than NSAIDs but its analgesic efficacy is probably low.
If additional pain relief is needed, an NSAID can be combined with paracetamol. These drugs are used in courses of 7 to 21 days at a time. For hip and knee osteoarthritis different NSAIDs are probably equally effective, and the choice of the drug should be based on safety and tolerability. For safe use of NSAIDs, see Safe Use of Non-Steroidal Anti-Inflammatory Drugs (Nsaids).
Use of COX-2 inhibitors can be considered at least in situations where the use of non-selective NSAIDs involves an increased risk of gastrointestinal bleeding. Another option is to combine a proton pump inhibitor (or misoprostol) with an NSAID.
Topical NSAIDs Topical Nsaids for Chronic Musculoskeletal Pain in Adults administered as creams are more effective than placebo and have fewer adverse effects than oral preparations. Certain herbal products (capsaicin, comfrey) have been found to have effects comparable with NSAID gel Topical Herbal Therapies for Treating Osteoarthritis.
In the most severe cases of osteoarthritic pain, also opioids Non-Tramadol Opioids for Osteoarthritis of the Knee or Hip may sometimes be needed, e.g. a combination of paracetamol with codeine, or tramadol; the beneficial effect of tramadol is, however, weak Tramadol for Osteoarthritis. Adverse effects limit the use of opioids and the duration of treatment should be as short as possible.

Glucocorticoids

An intra-articular, long-acting glucocorticoid occasionally gives relief, particularly when symptoms of inflammation or intra-articular crystal deposition are present Local Glucocorticoid Injections in Soft Tissues and Joints.
A glucocorticoid should not be injected into a dry joint.
In knee osteoarthritis the best response is obtained with short-term use Intra-Articular Corticosteroid for Treatment of Osteoarthritis of the Knee.
Short-term immobilization after a corticosteroid injection further alleviates joint irritation.

Hyaluronate

It is uncertain whether intra-articular hyaluronate provides clinically significant benefit in the treatment of osteoarthritis Intra-Articular Hyaluronic Acid for Knee Osteoarthritis. Hyaluronate must not be used as the first-line therapy.
Three to five intra-articular injections are usually given at one-week intervals.
When considering the use of intra-articular hyaluronate, the price (health centres pay the costs of any pharmacotherapy given there), labour intensity (each treatment session requires an appointment with a doctor) and the risk of complications associated with intra-articular puncture should be taken into account.

Glucosamine and chondroitin

Glucosamine Glucosamine in the Treatment of Osteoarthritis and chondroitin Chondroitin for Osteoarthritis may be effective for pain and functional impairment in some patients but the evidence is controversial. The drugs are quite well tolerated. The most common adverse effects associated with their use are mild gastrointestinal complaints.
In the absence of good alternatives, however, a therapeutic trial of 1 to 3 months may be indicated. A trial period can be repeated after a sufficient pause. The benefit should be assessed by the patient.

Other drugs

Diacerein Diacerein for Osteoarthritis may have some effect on joint pain and the progression of osteoarthritis in the hip but diarrhoea commonly seen as its adverse effect and possible liver toxicity limit its use. The availability of the drug varies from country to country. See also local and international restrictions on its use http://www.ema.europa.eu/en/medicines/human/referrals/diacerein-containing-medicines-oral-administration.

Herbal products

Of oral herbal products, Boswellia serrata and the combination of avocado and soyabean have been found to alleviate the symptoms of osteoarthritis Oral Herbal Therapies for Treating Osteoarthritis. There is no certainty about the duration or clinical significance of the effect. No severe adverse effects have been found to be associated with these products.

Hip osteoarthritis

Restricted range of motion in hip osteoarthritis: video Restricted Range of Motion of the Hip Caused by Osteoarthritis
Provision of instructions for physical exercise, in particular, is important for both treatment and prevention of the disease and should be started immediately after diagnosis.
The patient must be encouraged to stay active. Physical exercise reduces pain and improves joint function Exercise for Osteoarthritis of the Hip. Swimming, cycling and walking on soft terrain are good sports.
Physiotherapy may be helpful in mild hip osteoarthritis.
- Abduction exercises are best performed when lying on the back, extension training when lying on the side.
- If active stretching is not sufficient, contractures are treated with passive stretching of the flexor and adductor muscles with a pre-treatment regimen (warming with ultrasound and massage).
Technical devices may be necessary if the restriction of hip movement is considerable.
- A long-handled grabber, a stocking aid, raising the height of the bed and a special chair may be necessary.

Knee osteoarthritis

There is a dull ache that gets worse with movement and is alleviated at rest but as the disease progresses the ache may become constant and also bother the patient at night.
As the arthritis of the knee progresses, varus-valgus axis misalignment increases and aggravates the condition (pictures 1 2). Swelling may develop in the joint.
For assessing the range of motion of the knee, see video Assessing Range of Motion of the Knee.
Self-directed exercise is effective Exercise for Osteoarthritis of the Knee. Swimming, cross-country skiing and cycling are good sports. When the pain is severe, isometric exercises alone with resistance increased gradually may be suitable.
Provide the patient with appropriate patient education materials for self-directed exercise.
Physiotherapy is beneficial in the early stages of independent training in order to teach the patient the right exercises.
The aim of physiotherapy is to restore full range of movement. Thermal therapy can be used to alleviate pain during treatment. Investigated treatments include e.g. ultrasound Therapeutic Ultrasound for Osteoarthritis of the Knee, superficial heat, cold Thermotherapy for Treatment of Osteoarthritis), TENS Transcutaneous Electrical Nerve Stimulation for Knee Osteoarthritis, electroanalgesia Transcutaneous Electrical Nerve Stimulation for Knee Osteoarthritis and electromagnetic fields Electromagnetic Fields for the Treatment of Osteoarthritis, but their benefits have not been reliably demonstrated.
Insoles or braces do not have any significant effect on joint pain, stiffness or function or the patient's quality of life Transcutaneous Electrical Nerve Stimulation for Knee Osteoarthritis.

Surgical management Continuous Passive Motion Following Total Knee Arthroplasty in People with Arthritis, Multidisciplinary Rehabilitation after Joint Replacement at the Hip and Knee

Arthroscopy
- Arthroscopy is not an effective treatment option in knee osteoarthritis Arthroscopic Debridement for Knee Osteoarthritis. Arthroscopic debridement or lavage Joint Lavage for Osteoarthritis of the Knee does not affect pain or functional ability in patients with knee osteoarthritis.
- According to current view, arthroscopy does not either have a role in hip joint degeneration.
Osteotomy
- Knee osteotomy Osteotomy for Treating Knee Osteoarthritis aims at reducing symptoms on the affected side by transferring load and strain towards the unaffected side through cutting of the tibial bone, changing its alignment and fusing it to a new position.
- Hip osteotomy has been used in the treatment of a dysplastic hip joint in order to prevent secondary osteoarthritis.
Joint replacement surgery Cemented, Cementless or Hybrid Fixation Options in Total Knee Arthroplasty for Osteoarthritis and other Non-Traumatic Diseases, Retention Versus Sacrifice of the Posterior Cruciate Ligament in Total Knee Arthroplasty for Treating Osteoarthritis, Mobile Bearing Vs Fixed Bearing Prostheses for Total Knee Arthroplasty
- Joint replacement surgery often considerably improves the patient's quality of life.
- Pain or deterioration of functional ability together with progression of radiological findings form the most significant indications for joint replacement surgery, but the final treatment decision should be made individually.
- Patient should be referred for urgent surgery if they have
  - an imminent risk of fracture
  - rapidly progressing joint deformity
  - developing bone necrosis
  - constant pain at night
  - constant pain at rest during the day
  - significant functional limitations.
- Non-urgent surgery may be warranted if the patient has
  - clear and disturbingly limited range of joint mobility
  - weekly exertion-induced pain that clearly restricts exercising
  - moderate functional limitations.

References

Leaney AA, Lyttle JR, Segan J et al. Antidepressants for hip and knee osteoarthritis. Cochrane Database Syst Rev 2022;(10):CD012157. [PubMed]
O'Connor D, Johnston RV, Brignardello-Petersen R et al. Arthroscopic surgery for degenerative knee disease (osteoarthritis including degenerative meniscal tears). Cochrane Database Syst Rev 2022;(3):CD014328. [PubMed]
da Costa BR, Pereira TV, Saadat P et al. Effectiveness and safety of non-steroidal anti-inflammatory drugs and opioid treatment for knee and hip osteoarthritis: network meta-analysis. BMJ 2021;(375):n2321. [PubMed]
Deyle GD, Allen CS, Allison SC et al. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. N Engl J Med 2020;382(15):1420-1429. [PubMed]

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