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Not affiliated with the Royal Australasian College of Surgeons.

Hip Osteoarthritis

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Contents
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Hip Osteoarthritis

Comprehensive exam-ready guide to hip OA - diagnosis, conservative treatment, THA indications

complete
Updated: 2025-12-17
High Yield Overview

HIP OSTEOARTHRITIS

Joint Space Narrowing | Conservative First | THA When Failed

10%Adults over 60
PrimaryMost common type
95%+THA 15yr survival
GroinTypical pain location

KELLGREN-LAWRENCE GRADING

Grade 1
PatternDoubtful narrowing, possible osteophytes
TreatmentEarly changes
Grade 2
PatternDefinite osteophytes, possible narrowing
TreatmentMild OA
Grade 3
PatternMultiple osteophytes, definite narrowing
TreatmentModerate OA
Grade 4
PatternLarge osteophytes, marked narrowing, bone-on-bone
TreatmentSevere OA

Critical Must-Knows

  • Groin pain with activity is classic presentation
  • Radiographs: JSN, osteophytes, sclerosis, cysts
  • Conservative FIRST: weight loss, PT, NSAIDs, injections
  • THA when conservative fails and quality of life impaired
  • Primary OA most common; secondary includes AVN, DDH, FAI

Examiner's Pearls

  • "
    Internal rotation first motion lost
  • "
    AP pelvis + lateral of affected hip for imaging
  • "
    Young patients consider hip preservation before THA
  • "
    Avoid THA in active infection, poor health that precludes surgery
AP pelvis radiograph showing bilateral hip osteoarthritis
Click to expand
AP pelvis radiograph demonstrating bilateral hip osteoarthritis with joint space narrowing, subchondral sclerosis, and early osteophyte formation. The white arrow indicates the more severely affected left hip with near-complete joint space loss.Credit: PMC - CC BY 4.0

Clinical Imaging

Imaging Gallery

AP hip radiograph with annotated osteoarthritis features
Click to expand
AP hip radiograph with black arrows demonstrating the classic radiographic features of hip osteoarthritis: superior joint space narrowing, subchondral sclerosis, and osteophyte formation at the joint margins (LOSS mnemonic).Credit: PMC - CC BY 4.0

Critical Exam Concepts

Groin Pain

True hip pathology causes GROIN pain. Lateral hip pain is often trochanteric bursitis. Buttock pain may be referred from spine.

Conservative First

Always trial conservative measures before THA. Weight loss, physiotherapy, walking aids, NSAIDs, injections. Surgery for failed conservative.

Radiograph Findings

Classic X-ray changes: Joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts. LOSS is mnemonic.

Young Patients

Consider hip preservation first in young patients - osteotomy, arthroscopy for FAI/labral tears. THA means revision surgery in future.

Hip OA vs Other Hip Conditions

ConditionPain LocationKey FeatureImaging
Hip OAGroinActivity-related, stiffnessJSN, osteophytes
Trochanteric bursitisLateralPoint tenderness GTNormal or bursitis
AVNGroinRisk factors (steroids, alcohol)Crescent sign, collapse
Labral tearGroin, clickingYounger, mechanical symptomsMRA shows tear
Mnemonic

LOSSOA X-ray Findings

L
Loss of joint space
Narrowing, bone-on-bone
O
Osteophytes
Bone spurs at margins
S
Subchondral sclerosis
Dense bone under cartilage
S
Subchondral cysts
Geodes in bone

Memory Hook:LOSS of cartilage causes all these changes!

Mnemonic

DAFTSecondary OA Causes

D
DDH
Developmental dysplasia of hip
A
AVN
Avascular necrosis
F
FAI
Femoroacetabular impingement
T
Trauma
Post-traumatic OA

Memory Hook:DAFT causes lead to secondary OA!

Mnemonic

WIPEConservative Treatment

W
Weight loss
Reduces joint loading
I
Injections
Steroid or hyaluronic acid
P
Physiotherapy
Muscle strengthening, ROM
E
Exercise and NSAIDs
Low impact, anti-inflammatories

Memory Hook:WIPE out the pain with conservative treatment!

Overview and Epidemiology

Primary vs Secondary OA

Primary OA = no identifiable cause (wear and tear). Secondary OA = underlying condition (DDH, AVN, FAI, trauma, inflammatory arthritis). Secondary OA often affects younger patients.

Epidemiology

  • 10% of adults over 60
  • Increases with age
  • More symptomatic in females
  • Obesity major risk factor
  • Leading indication for THA

Risk Factors

  • Age: Primary risk factor
  • Obesity: Increased joint loading
  • Genetics: Strong family history component
  • Occupation: Heavy labor
  • Prior pathology: DDH, Perthes, SCFE, FAI

Pathophysiology and Anatomy

Hip Joint Anatomy

Ball and socket: Femoral head articulates with acetabulum.

Articular cartilage: Hyaline cartilage covers both surfaces. 3-4mm thick.

Labrum: Fibrocartilaginous rim deepens socket by 22%.

Capsule: Strong, reinforced by iliofemoral, pubofemoral, ischiofemoral ligaments.

Blood supply: MFCA (primary to head), LFCA, artery of ligamentum teres.

OA Disease Process

AP hip radiograph showing progressive joint space narrowing in osteoarthritis
Click to expand
AP hip radiograph demonstrating joint space narrowing (KL Grade II) with black arrows highlighting the loss of cartilage space. Note the superolateral pattern of involvement typical of primary hip OA. Same patient progression series from KL I to KL II.Credit: Kamimura M et al. - Open Rheumatol J (CC BY 4.0)

Initiation: Cartilage damage from mechanical or biological factors.

Progression:

  • Cartilage degradation (matrix metalloproteinases)
  • Subchondral bone changes
  • Synovitis (low-grade inflammation)
  • Osteophyte formation

End-stage: Bone-on-bone contact, severe pain.

OA is whole joint disease - not just cartilage.

OA Patterns in Hip

Superior pole (lateral): Most common. Weight-bearing area.

Medial pole (superomedial migration): Less common. Thin bone.

Concentric: Uniform loss. Often inflammatory etiology.

Pattern affects surgical planning (acetabular bone stock).

Rule Out Secondary Causes

In younger patients (under 50) with hip OA, always consider secondary causes - DDH, AVN, FAI, SCFE sequelae. These affect treatment planning and prognosis.

Classification Systems

AP hip radiograph demonstrating subchondral changes in osteoarthritis
Click to expand
AP hip radiograph showing KL Grade II hip osteoarthritis after pain resolution. Black arrows indicate joint space narrowing and subchondral sclerosis characteristic of progressive cartilage loss. Same patient series demonstrating radiographic-clinical dissociation.Credit: Kamimura M et al. - Open Rheumatol J (CC BY 4.0)

Kellgren-Lawrence Grading

GradeDescriptionClinical Correlation
0No features of OANormal
1Doubtful JSN, possible osteophytesMay be asymptomatic
2Definite osteophytes, possible JSNMild symptoms
3Moderate osteophytes, definite JSN, some sclerosisModerate symptoms
4Large osteophytes, marked JSN, severe sclerosis, cystsSevere, THA candidate

Widely used, good inter-observer reliability for extremes.

Tonnis Classification

Grade 0: Normal joint.

Grade 1: Increased sclerosis, slight JSN, no or slight osteophytes.

Grade 2: Small cysts, moderate JSN, moderate osteophytes.

Grade 3: Large cysts, severe JSN, severe osteophytes, deformity.

Commonly used in hip preservation literature.

Etiology Classification

Primary (idiopathic):

  • No identifiable cause
  • Wear and tear
  • Most common in elderly

Secondary:

  • DDH (dysplasia)
  • AVN
  • FAI (cam or pincer)
  • Post-traumatic
  • Inflammatory (RA, AS)
  • SCFE or Perthes sequelae

Understanding etiology guides treatment selection and prognosis.

Clinical Assessment

History

  • Pain: Groin (true hip), activity-related
  • Stiffness: Morning, improves with movement
  • Function: Walking distance, stairs, ADLs
  • Night pain: Advanced disease
  • Impact on QoL: Work, recreation, sleep

Examination

  • Gait: Antalgic, Trendelenburg
  • ROM: Internal rotation lost first
  • FABER/FADIR: Provoke pain
  • Leg length: May be shortened
  • Trendelenburg: Abductor weakness

Internal Rotation First

Internal rotation is the first motion lost in hip OA and often the most painful. Check ROM with patient supine and hip at 90 degrees flexion for accurate assessment.

Outcome Measures

Harris Hip Score: Classic outcome measure. Pain, function, ROM, deformity.

Oxford Hip Score: Patient-reported, 12 questions. Widely used.

HOOS: Hip Disability and Osteoarthritis Outcome Score. Comprehensive.

Investigations

Plain Radiographs

Views:

  • AP pelvis (weight-bearing if possible)
  • Lateral of affected hip (cross-table or frog-leg)

Findings (LOSS):

  • Loss of joint space
  • Osteophytes
  • Subchondral sclerosis
  • Subchondral cysts

May underestimate cartilage loss compared to MRI.

MRI Assessment

Indications:

  • Early OA with normal X-ray
  • Rule out AVN
  • Assess labral pathology
  • Young patient considering preservation

Findings: Cartilage loss, bone edema, labral tears, effusion.

Not required for typical end-stage OA before THA.

CT Assessment

Indications:

  • Preoperative planning for THA
  • Assess acetabular version/coverage
  • Complex deformity (DDH, protrusio)

3D reconstructions: Helpful for surgical planning.

Templating software uses CT for component sizing.

Weight-Bearing Films

Weight-bearing AP pelvis shows true joint space narrowing. Non-weight-bearing films may overestimate cartilage thickness. Always try to obtain weight-bearing views.

Management Algorithm

📊 Management Algorithm
hip osteoarthritis management algorithm
Click to expand
Management algorithm for hip osteoarthritisCredit: OrthoVellum

Hip OA Treatment Algorithm

Management Pathway

DiagnosisConfirm OA

Clinical history and examination. Radiographs. Rule out secondary causes.

ConservativeFirst Line

Weight loss, exercise, PT, NSAIDs, walking aids. Trial injections if needed.

Failed ConservativeReassess

If quality of life significantly impaired despite conservative measures, consider surgery.

SurgeryOptions

THA (most common). Consider preservation surgery in young if appropriate.

Non-Operative Management

Lifestyle:

  • Weight loss (reduces joint loading)
  • Activity modification (avoid high impact)
  • Walking aids (cane in opposite hand)

Physiotherapy:

  • Muscle strengthening (abductors, quads)
  • ROM maintenance
  • Pool exercises

Medications:

  • Acetaminophen (first line)
  • NSAIDs (with caution for GI, renal, CV)
  • Topical NSAIDs

Injections:

  • Intra-articular steroid (short-term relief)
  • Hyaluronic acid (controversial evidence)

Most patients trial multiple conservative options before considering surgery.

Surgical Options

Total Hip Arthroplasty:

  • Gold standard for end-stage OA
  • Excellent outcomes 95%+ at 15 years
  • Cemented vs uncemented

Hip Preservation (Young Patients):

  • Hip arthroscopy (labral repair, FAI correction)
  • Periacetabular osteotomy (dysplasia)
  • Femoral osteotomy (varus/valgus)

Hip Resurfacing:

  • Metal-on-metal (concerns with ALVAL)
  • Selected young active males
  • Less common now

Choice of procedure depends on patient age, activity level, and joint preservation potential.

Surgical Considerations

AP hip radiograph showing early hip osteoarthritis (KL Grade I)
Click to expand
AP hip radiograph demonstrating early hip osteoarthritis (KL Grade I) at symptom onset. Black arrows highlight subtle joint space narrowing - the earliest radiographic sign. This is the stage where patients often present with groin pain but relatively preserved joint space. Note: Progressive disease may eventually require total hip arthroplasty.Credit: Kamimura M et al. - Open Rheumatol J (CC BY 4.0)

Indications for THA

Appropriate:

  • Failed conservative treatment
  • Significant functional impairment
  • Pain affecting quality of life
  • Radiographic evidence of OA

Relative contraindications:

  • Active infection
  • Poor health precluding surgery
  • Unrealistic expectations
  • Neuropathic joint (Charcot)

Age alone is not a contraindication.

THA Surgical Approaches

Posterior: Most common. Good exposure. Dislocation risk.

Anterior (DAA): Muscle sparing. Faster recovery. Learning curve.

Lateral (Hardinge): Good exposure. Abductor risk.

Anterolateral: Balance of exposure and recovery.

Surgeon experience most important factor.

Special Considerations

Under 50:

  • Consider hip preservation first if appropriate
  • Rule out FAI, labral pathology
  • Discuss revision likelihood
  • Uncemented components preferred
  • Activity modification counseling

THA in young patients has good outcomes but higher revision rates.

Young Patient Counseling

Young patients (under 50) undergoing THA must be counseled about revision surgery probability. Current implants may last 20+ years but revision is likely within their lifetime.

Complications

ComplicationConservativeTHA
GI bleedingNSAIDs riskN/A
InfectionN/A1% (PJI)
DislocationN/A1-3%
DVT/PEN/ADespite prophylaxis
Leg length discrepancyN/AMeasured and addressed
LooseningN/ALong-term, leads to revision

Conservative Treatment Risks

NSAIDs have significant risks: GI bleeding, renal impairment, cardiovascular events. Use lowest dose for shortest time. Consider PPI cover. Acetaminophen is safer for chronic use.

Postoperative Care (THA)

THA Recovery

Day 0-1Immediate

Mobilize day of surgery. DVT prophylaxis. Pain control. Precautions if posterior approach.

Week 1-2Early

Discharge home 1-3 days. PT, gait aids. Wound care. Continue DVT prophylaxis.

Week 2-6Progressive

Increase mobility. Wean walking aids. Drive when safe. Return to desk work.

Month 3-6Full Recovery

Most return to pre-morbid activities. Low-impact sport allowed. Full function.

Dislocation Precautions

Posterior approach precautions: Avoid hip flexion greater than 90 degrees, internal rotation, adduction past midline. Duration varies (6-12 weeks). Anterior approach may have fewer precautions.

Outcomes and Prognosis

THA Outcomes

Survival: 95%+ at 15 years in correctly selected patients.

Function: Dramatic pain relief and functional improvement.

Satisfaction: Over 90% satisfied.

Revision risk: Higher in young, active patients. Polyethylene wear, loosening, infection main causes.

Non-Operative Outcomes

Natural history: Progressive deterioration. Rate varies.

Conservative treatment: Symptom management. Does not alter disease progression.

Evidence Base and Key Studies

Conservative Management of Hip OA

1
NICE Guidelines • NICE (2022)
Key Findings:
  • Exercise and weight loss first line
  • NSAIDs with caution
  • Intra-articular steroid for flares
  • THA when conservative fails
Clinical Implication: Conservative measures should be exhausted before THA.
Limitation: Guidelines, not RCT.

THA vs Conservative for Hip OA

1
NEJM RCT • NEJM (2018)
Key Findings:
  • THA superior to conservative at 12 months
  • Greater pain relief and function
  • Quality of life improvement
  • Cost-effective
Clinical Implication: THA is highly effective when conservative measures fail.
Limitation: Crossover in conservative arm.

Long-Term THA Survival

2
National Joint Registry • NJR Annual Report (2023)
Key Findings:
  • 95% survival at 15 years
  • Higher revision in young
  • Cemented vs uncemented similar in elderly
  • Hybrid fixation common
Clinical Implication: THA has excellent long-term survival but younger patients have higher revision.
Limitation: Registry data, observational.

Intra-articular Steroids for Hip OA

1
McAlindon TE et al. • JAMA (2017)
Key Findings:
  • Short-term pain relief (weeks)
  • No disease modification
  • Repeated injections safe
  • Consider for flares
Clinical Implication: Steroid injections provide short-term relief, useful for flares or temporizing.
Limitation: Does not alter disease course.

Exercise for Hip OA

1
Cochrane Review • Cochrane Database (2014)
Key Findings:
  • Land-based exercise reduces pain
  • Improves function
  • Water-based exercise also effective
  • Safe and recommended
Clinical Implication: Exercise is evidence-based first-line treatment for hip OA.
Limitation: Modest effect sizes.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Classic Hip OA

EXAMINER

"A 68-year-old woman presents with 2 years of progressive right groin pain worse with walking and stairs. She has stiffness in the morning for 20 minutes. X-rays show joint space narrowing, osteophytes, and subchondral sclerosis. She has not tried any formal treatment. What is your management?"

EXCEPTIONAL ANSWER
This is a classic presentation of primary hip osteoarthritis with typical groin pain, activity-related symptoms, and radiographic changes (LOSS findings). My management would start with conservative measures. First-line treatment includes: weight loss if applicable (reduces joint loading), physiotherapy for strengthening hip abductors and quadriceps (improves dynamic stability), activity modification (avoid high-impact activities, continue low-impact exercise like swimming or cycling), walking aids (cane in the opposite hand reduces hip loading by 20%), and analgesia starting with acetaminophen. If inadequate, I would add topical or oral NSAIDs with caution for GI, renal, and cardiovascular risks - PPI cover if needed. If she has a significant flare or wants to defer surgery, I would offer intra-articular steroid injection for short-term relief. I would reassess at 3-6 months. If conservative measures fail to provide adequate symptom control and her quality of life remains significantly impaired, I would discuss total hip arthroplasty, which has excellent outcomes with 95%+ survival at 15 years.
KEY POINTS TO SCORE
Classic groin pain presentation
Radiograph confirms OA (LOSS)
Conservative treatment FIRST
Weight loss, PT, NSAIDs, walking aids
THA if conservative fails
COMMON TRAPS
✗Jumping straight to THA
✗Not trialing conservative measures
✗Ordering unnecessary MRI
✗Missing alternative diagnoses
LIKELY FOLLOW-UPS
"What conservative options are evidence-based?"
"When would you recommend THA?"
"What are the X-ray findings in OA?"
VIVA SCENARIOChallenging

Scenario 2: Young Patient with OA

EXAMINER

"A 42-year-old active man presents with bilateral hip pain and stiffness. X-rays show moderate bilateral hip OA with acetabular dysplasia (CE angle 18 degrees). He is frustrated with symptoms affecting his tennis. What is your approach?"

EXCEPTIONAL ANSWER
This is secondary hip OA in a young patient due to underlying developmental dysplasia of the hip (DDH) - the low center-edge angle of 18 degrees (normal greater than 25) indicates inadequate acetabular coverage. The young age and underlying dysplasia require careful consideration. My approach would first focus on optimizing conservative measures: physiotherapy, NSAIDs, activity modification (likely needs to reduce high-impact tennis). However, he needs to understand the underlying mechanical problem. For a 42-year-old with dysplasia, I would discuss hip preservation surgery if his cartilage is still reasonable - specifically periacetabular osteotomy (PAO) to improve acetabular coverage. This requires adequate remaining cartilage (less than mild OA). If his OA is already moderate-severe, PAO is less likely to succeed. CT is helpful to assess acetabular version and cartilage. If OA is too advanced or he is not a PAO candidate, I would discuss THA, counseling carefully about activity modification (limit high-impact sports), implant longevity (may need revision in his lifetime), and realistic expectations. For bilateral disease, I would address the more symptomatic side first.
KEY POINTS TO SCORE
Secondary OA due to DDH
Young patient - consider hip preservation
PAO if cartilage adequate
THA if too advanced, counsel re revision
Activity modification required
COMMON TRAPS
✗Rushing to THA without considering preservation
✗Not recognizing dysplasia as cause
✗Not counseling about revision risk
✗Continuing high-impact sport after THA
LIKELY FOLLOW-UPS
"What is the CE angle cutoff for dysplasia?"
"What is a periacetabular osteotomy?"
"How would you counsel about THA at this age?"
VIVA SCENARIOCritical

Scenario 3: Failed Conservative Treatment

EXAMINER

"A 72-year-old woman has tried physiotherapy, lost 8kg, uses a walking stick, and has had two steroid injections over 18 months. She still has significant right hip pain limiting her to walking 200m and disturbing her sleep. X-rays show bone-on-bone changes. She asks about her options. What would you advise?"

EXCEPTIONAL ANSWER
This patient has exhausted appropriate conservative measures over a sufficient timeframe and continues to have significant functional impairment with end-stage radiographic changes. She is an appropriate candidate for total hip arthroplasty. In counseling her, I would explain that THA is highly effective for her condition with over 95% of implants functioning well at 15 years. The surgery would be expected to dramatically reduce her pain and improve her walking capacity. At 72, revision surgery in her lifetime is unlikely but possible. I would discuss the surgical approach options (I would use my preferred approach which would be posterior or anterior depending on my training), anesthesia options, hospital stay (1-3 days), DVT prophylaxis, pain management, and rehabilitation. I would discuss specific risks including infection (1%), dislocation (1-3%, depends on approach), DVT/PE, leg length difference, nerve injury, and bleeding. I would also discuss realistic expectations - she should expect significant pain relief and improved function, but the hip will not be completely normal. Activity recommendations would include low-impact activities like walking, swimming, cycling, golf but avoiding high-impact sports or heavy manual labor.
KEY POINTS TO SCORE
Failed adequate conservative trial
End-stage radiographic OA
THA indicated - excellent outcomes
Counsel on risks and realistic expectations
Activity recommendations post-THA
COMMON TRAPS
✗Not recognizing she has exhausted conservative options
✗Continuing to defer surgery inappropriately
✗Incomplete consent discussion
✗Promising completely normal hip
LIKELY FOLLOW-UPS
"What approach would you use?"
"What are the main risks to discuss?"
"How do you manage DVT prophylaxis?"

MCQ Practice Points

Classic Presentation

Q: Where does true hip pathology cause pain? A: GROIN. Lateral pain = trochanteric bursitis. Buttock pain = sacroiliac or lumbar spine.

First Motion Lost

Q: What is the first motion lost in hip OA? A: Internal rotation. Often most painful as well. Test at 90 degrees flexion.

X-ray Findings

Q: What are the radiographic features of OA (LOSS)? A: Loss of joint space, Osteophytes, Subchondral Sclerosis, Subchondral cysts.

Kellgren-Lawrence

Q: What is Kellgren-Lawrence Grade 4? A: Large osteophytes, marked joint space narrowing, severe sclerosis, cysts, bone-on-bone. End-stage OA.

First Line Treatment

Q: What is first-line treatment for hip OA? A: Conservative: weight loss, exercise, physiotherapy, acetaminophen, walking aids. NSAIDs with caution.

THA Survival

Q: What is 15-year survival of THA? A: Greater than 95% in correctly selected patients. Higher revision in young, active patients.

Australian Context

Clinical Practice

  • High THA rates per capita
  • National Joint Replacement Registry (AOANJRR)
  • Registry data guides implant selection
  • Conservative treatment emphasized
  • Mostly uncemented THA

Funding and Access

  • Public system THA available
  • Variable wait times (12-24 months)
  • Private faster access
  • Medicare/private insurance covers
  • PT accessible via Medicare

Orthopaedic Exam Relevance

Hip OA is extremely common in viva. Know conservative treatment first, THA indications, and be able to consent a patient. Discuss approaches, complications, and manage expectations appropriately.

HIP OSTEOARTHRITIS

High-Yield Exam Summary

Presentation

  • •Groin pain (true hip)
  • •Activity-related, improves with rest
  • •Morning stiffness (less than 30 min)
  • •Internal rotation first lost

Radiograph (LOSS)

  • •Loss of joint space
  • •Osteophytes
  • •Subchondral Sclerosis
  • •Subchondral cysts

Conservative (WIPE)

  • •Weight loss
  • •Injections (steroid)
  • •Physiotherapy
  • •Exercise and NSAIDs

Kellgren-Lawrence

  • •Grade 1: doubtful narrowing
  • •Grade 2: definite osteophytes
  • •Grade 3: definite narrowing
  • •Grade 4: bone on bone

THA Indications

  • •Failed conservative treatment
  • •Significant functional impairment
  • •Impact on quality of life
  • •Radiographic OA

Secondary Causes (DAFT)

  • •DDH (dysplasia)
  • •AVN
  • •FAI
  • •Trauma
Quick Stats
Reading Time68 min
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