Coxarthrosis is arthrosis of the hip joint. It develops gradually, over several years, is prone to progression, can be both unilateral and bilateral. It is accompanied by pain and restriction of movements in the joint. In the later stages, there is atrophy of the thigh muscles and shortening of the limb. The diagnosis is established on the basis of clinical symptoms and the results of radiography. In the early stages of coxarthrosis, treatment is conservative. In case of joint destruction, especially in young and middle–aged patients, surgery (endoprosthetics) is indicated.
M16 Coxarthrosis [hip arthrosis]
Coxarthrosis (osteoarthritis or deforming arthrosis of the hip joint) is a degenerative-dystrophic disease. Usually develops at the age of 40 years and older. It can be a consequence of various injuries and diseases of the joint. Sometimes it occurs for no apparent reason. Coxarthrosis is characterized by a gradual progressive course. Conservative methods of treatment are used in the early stages. In the later stages, it is possible to restore the function of the joint only by surgery.
In orthopedics and traumatology, coxarthrosis is one of the most common arthrosis. The high frequency of its development is due to a significant load on the hip joint and the widespread prevalence of congenital pathology – joint dysplasia. Women suffer from coxarthrosis a little more often than men.
There are primary (arising for unknown reasons) and secondary (developed as a result of other diseases) arthrosis of the hip joint.
Secondary coxarthrosis can be a consequence of the following diseases:
- Hip dysplasia.
- Congenital dislocation of the hip.
- Diseases of Perthes.
- Aseptic necrosis of the femoral head.
- Infectious lesions and inflammatory processes (for example, hip arthritis).
- Suffered injuries (traumatic dislocations, hip fractures, pelvic fractures).
Coxarthrosis can be both unilateral and bilateral. In primary coxarthrosis, concomitant damage to the spine (osteochondrosis) and knee joint (gonarthrosis) is often observed.
- Among the factors that increase the likelihood of developing coxarthrosis are:
- Constant increased stress on the joint. It is most often observed in athletes and in overweight people.
- Circulatory disorders, hormonal changes, metabolic disorders.
- Pathology of the spine (kyphosis, scoliosis) or feet (flat feet).
- Elderly and senile age.
- Sedentary lifestyle.
By itself, coxarthrosis is not inherited. However, certain features (metabolic disorders, skeletal structure and weakness of cartilage tissue) can be inherited by a child from his parents. Therefore, in the presence of blood relatives suffering from coxarthrosis, the likelihood of the disease increases somewhat.
The hip joint is formed by two bones: the iliac and femoral. The femoral head articulates with the acetabulum of the ilium, forming a kind of “hinge”. During movements, the acetabulum remains stationary, and the femoral head moves in various directions, providing flexion, extension, retraction, reduction and rotational movements of the thigh.
During movements, the articular surfaces of the bones slide freely relative to each other, thanks to the smooth, elastic and durable hyaline cartilage covering the acetabulum cavity and the femoral head. In addition, hyaline cartilage performs a cushioning function and participates in the redistribution of load during movement and walking.
There is a small amount of articular fluid in the joint cavity, which plays the role of lubrication and provides nutrition to hyaline cartilage. The joint is surrounded by a dense and durable capsule. Above the capsule are large femoral and gluteal muscles that provide movement in the joint and, along with hyaline cartilage, are also shock absorbers that protect the joint from injury in case of unsuccessful movements.
With coxarthrosis, the articular fluid becomes thicker and more viscous. The surface of hyaline cartilage dries out, loses its smoothness, and becomes covered with cracks. Due to the resulting roughness, the cartilages are constantly injured against each other during movements, which causes their thinning and aggravates pathological changes in the joint. As coxarthrosis progresses, the bones begin to deform, “adapting” to the increased pressure. The metabolism in the joint area worsens. In the late stages of coxarthrosis, pronounced atrophy of the muscles of the diseased limb is observed.
The main symptoms of the disease include pain in the joint, groin, hip and knee joint. Also, with coxarthrosis, stiffness of movements and joint stiffness, gait disorders, lameness, atrophy of the thigh muscles and shortening of the limb on the affected side are observed. A characteristic feature of coxarthrosis is the restriction of withdrawal (for example, the patient has difficulty trying to sit “astride” a chair). The presence of certain signs and their severity depends on the stage of coxarthrosis. The first and most permanent symptom is pain.
With coxarthrosis of the 1st degree, patients complain of periodic pain that occurs after physical exertion (running or long walking). The pain is localized in the joint area, less often in the hip or knee area. After a rest, it usually disappears. Gait in coxarthrosis of the 1st degree is not disturbed, movements are preserved in full, there is no muscle atrophy.
On the X-ray of a patient suffering from grade 1 coxarthrosis, mild changes are detected: moderate uneven narrowing of the articular gap, as well as bone growths around the outer or inner edge of the acetabulum in the absence of changes from the head and neck of the femur.
With coxarthrosis of the 2nd degree, the pains become more intense, often appear at rest, radiate into the thigh and groin area. After considerable physical exertion, the patient with coxarthrosis begins to limp. The volume of movements in the joint decreases: the abduction and internal rotation of the hip is limited.
On X-rays with coxarthrosis of the 2nd degree, a significant uneven narrowing of the articular gap (more than half of the normal height) is determined. The femoral head shifts slightly upward, deforms and increases in size, and its contours become uneven. Bone growths with this degree of coxarthrosis appear not only on the inner, but also on the outer edge of the acetabulum and go beyond the cartilaginous lip.
With coxarthrosis, 3 degrees of pain become permanent, disturbing patients not only during the day, but also at night. Walking is difficult, when moving a patient with coxarthrosis is forced to use a cane. The amount of movement in the joint is sharply limited, the muscles of the buttock, thigh and lower leg are atrophied. The weakness of the abductor muscles of the thigh causes the deviation of the pelvis in the frontal plane and shortening of the limb on the diseased side. In order to compensate for the shortening that has occurred, the patient suffering from coxarthrosis, when walking, tilts the trunk to the sick side. Because of this, the center of gravity shifts, the load on the diseased joint increases dramatically.
Radiographs with coxarthrosis of the 3rd degree reveal a sharp narrowing of the articular gap, pronounced expansion of the femoral head and multiple bone growths.
The diagnosis of coxarthrosis is made on the basis of clinical signs and data from additional studies, the main of which is radiography. In many cases, X-rays make it possible to establish not only the degree of coxarthrosis, but also the cause of its occurrence. For example, an increase in the cervical-diaphyseal angle, obliquity and flattening of the acetabulum indicate dysplasia, and changes in the shape of the proximal part of the femur indicate that coxarthrosis is a consequence of Perthes’ disease or juvenile epiphysiolysis. Radiographs of patients with coxarthrosis may also reveal changes indicating injuries suffered.
CT and MRI can be used as other methods of instrumental diagnosis of coxarthrosis. Computed tomography makes it possible to study in detail pathological changes on the part of bone structures, and magnetic resonance imaging provides an opportunity to assess soft tissue disorders.
First of all, coxarthrosis should be differentiated from gonarthrosis (osteoarthritis of the knee joint) and osteochondrosis of the spine. Muscle atrophy that occurs at stages 2 and 3 of coxarthrosis can cause pain in the knee joint, which are often more pronounced than pain in the affected area. Therefore, when a patient complains of knee pain, a clinical (examination, palpation, determination of the volume of movements) examination of the hip joint should be performed, and if coxarthrosis is suspected, the patient should be referred for radiography.
Pain with radicular syndrome (compression of nerve roots) with osteochondrosis and some other diseases of the spine can mimic the pain syndrome with coxarthrosis. Unlike coxarthrosis, when the roots are squeezed, the pain occurs suddenly, after an unsuccessful movement, a sharp turn, lifting weights, etc., is localized in the buttock area and spreads along the back of the thigh. A positive symptom of tension is revealed – pronounced soreness when the patient tries to lift the straightened limb while lying on his back. At the same time, the patient freely moves his leg to the side, whereas in patients with coxarthrosis, the withdrawal is limited. It should be borne in mind that osteochondrosis and coxarthrosis can be observed simultaneously, therefore, in all cases, a thorough examination of the patient is necessary.
In addition, coxarthrosis is differentiated with trochanteritis – aseptic inflammation in the area of attachment of the gluteal muscles. Unlike coxarthrosis, the disease develops quickly, within 1-2 weeks, usually after an injury or significant physical exertion. The intensity of pain is higher than with coxarthrosis. There is no restriction of movement and shortening of the limb.
In some cases, with an atypical course of ankylosing spondylitis or reactive arthritis, symptoms resembling coxarthrosis may be observed. Unlike coxarthrosis, in these diseases, the peak of pain occurs at night. The pain syndrome is very intense, may decrease when walking. Morning stiffness is characteristic, which occurs immediately after waking up and gradually disappears within a few hours.
Orthopedists-traumatologists are engaged in the treatment of pathology. The choice of treatment methods depends on the symptoms and stage of the disease. Conservative therapy is performed at stages 1 and 2 of coxarthrosis. During the exacerbation of coxarthrosis, injectable blockades, nonsteroidal anti-inflammatory drugs (piroxicam, indomethacin, diclofenac, ibuprofen, etc.) are used. It should be borne in mind that drugs of this group are not recommended to be taken for a long time, since they can have a negative effect on internal organs and inhibit the ability of hyaline cartilage to recover.
To restore damaged cartilage in coxarthrosis, agents from the group of chondroprotectors (chondroitin sulfate, calf cartilage extract, etc.) are used. Vasodilators (cinnarizine, nicotinic acid, pentoxifylline, xanthinol nicotinate) are prescribed to improve blood circulation and eliminate spasm of small vessels. According to the indications, muscle relaxants (medications for muscle relaxation) are used.
With persistent pain syndrome, patients suffering from coxarthrosis may be prescribed intra-articular injections using hormonal drugs (hydrocortisone, triamcinolone, metipred). Treatment with steroids should be carried out with caution. In addition, local remedies are used for coxarthrosis – warming ointments, which do not have a pronounced therapeutic effect, however, in some cases relieve muscle spasm and reduce pain due to their “distracting” action. Also, with coxarthrosis, physiotherapy procedures (light therapy, ultrasound therapy, laser therapy, UHF, inductothermy, magnetotherapy), massage, manual therapy and therapeutic gymnastics are prescribed.
The diet for coxarthrosis has no independent therapeutic effect and is used only as a means to reduce weight. Reducing body weight reduces the load on the hip joints and, as a result, facilitates the course of coxarthrosis. In order to reduce the load on the joint, the doctor, depending on the degree of coxarthrosis, may recommend that the patient walk with a cane or crutches.
In the late stages (with grade 3 coxarthrosis), the only effective treatment is surgery – replacement of the destroyed joint with an endoprosthesis. Depending on the nature of the lesion, either a single-pole (replacing only the femoral head) or a two-pole (replacing both the femoral head and the acetabulum) prosthesis can be used.
Endoprosthesis surgery for coxarthrosis is performed as planned, after a full examination, under general anesthesia. In the postoperative period, antibiotic therapy is performed. The stitches are removed for 10-12 days, after which the patient is discharged for outpatient treatment. After endoprosthetics, rehabilitation measures are necessarily carried out.
In 95% of cases, joint replacement surgery for coxarthrosis provides complete restoration of limb function. Patients can work, move actively and even play sports. The average service life of the prosthesis, if all the recommendations are followed, is 15-20 years. After that, a second operation is necessary to replace the worn-out endoprosthesis.