Arthritis

Approximately 70 million Americans suffer from arthritis and about 300,000 total hip replacement procedures are performed each year for this condition. Arthritis is characterized by breakdown of the articular cartilage, with resultant pain and stiffness. The two most common types are osteoarthritis and rheumatoid arthritis.

Osteoarthritis is simply accelerated wear and tear of the joint. A previous injury may leave the joint damaged and susceptible to progressive breakdown. Variations in how the joint is shaped may lead to abnormal joint mechanics and accelerated wear. This is especially attributed to “dysplasia”, a condition where the socket is abnormally shallow; and “femoroacetabular impingement” (FAI), a condition where abnormal bony build-up around the acetabulum or femoral head may result in accelerated cartilage breakdown.

Arthritis of the hip is often a great imitator as far as how it behaves. Typically, we expect arthritis to come on gradually over time and be associated with advancing age. However, the onset of symptoms may sometimes be surprisingly sudden and people may experience intermittent episodes of spontaneous remission. It can also strike young adults even without a family history of disease, and may be isolated to a single joint.

Rheumatoid arthritis is the most common of a large group of inflammatory arthritides. This is characterized by a poorly controlled proliferation of the synovium, resulting in erosion of the articular surface. This is generally considered to be one of the most devastating of all non-lethal diseases. Chemotherapy agents are often used to try to arrest the synovial proliferation but, even if the synovium is brought into control, the resultant articular damage may continue to cause problems. Arthroscopic excision of the diseased synovium can be effective for cases unresponsive to pharmacological management. Arthroscopy cannot reverse the articular damage that has occurred, but sometimes debridement of the fragments and associated diseased tissue can be beneficial in reducing discomfort.

In general, arthroscopy in the presence of arthritis is sometimes considered, especially for younger patients if the x-rays do not show the joint to be too badly worn. The arthritis may continue to deteriorate in the future, eventually requiring a total hip replacement, but it is preferable to preserve the natural joint as long as possible. While an artificial hip is superior to a painful, worn out joint, it is not a normal hip and carries with it numerous concerns. These concerns include the seriousness of the procedure, life-long precautions that are necessary with an artificial joint, and the possibility of the artificial joint becoming painful and requiring revision.

Arthroscopy is an attractive consideration as a procedure that could potentially preserve the natural joint and it does not burn any bridges regarding future options. However, realistically, successful outcomes in the presence of significant arthritis have been reported only in upwards of 50% of cases with two year follow up and only slightly greater than one third of these cases after five years. Arthroscopic debridement for arthritis may not be a panacea, allowing patients to resume a fully active lifestyle, but may simply be an alternative that reduces discomfort and preserves the natural joint for a while before contemplating a replacement. An added benefit of postponing a hip replacement is that the technology and materials for these artificial joints keeps improving.

We are gaining an understanding of conditions that predispose people to developing various types of arthritis. Thus we are making significant strides in joint preserving strategies that may improve the long term outlook for some of these diseases.