ArticlePDF Available

Association between pain in the hip region and radiographic changes of osteoarthritis: Results from a population-based study


Abstract and Figures

The relationship between hip pain and radiographic change in the population is unclear due to lack of agreed definition for hip pain and difficulties in obtaining radiographs from asymptomatic random samples. Our objective was to assess the relationship between hip pain and radiographic change in osteoarthritis (OA) in a population sample aged over 45. One thousand and seventy-one responders to a postal questionnaire using a recently validated approach to defining hip pain were stratified into hip pain-positive and -negative groups and samples of each were X-rayed and scored for OA using both minimum joint space and the Croft score. The association between pain and X-ray score was estimated, weighting back to the age and gender distribution of the original population. Hip pain prevalence was 7% in males and 10% in females. Severe OA was present in 16% of those with and 3% of those without pain. Adjusting for age and gender, there was a very strong association of pain with severe OA [odds ratio (OR) 17.4, 95% confidence interval (CI) 3.0-102], but no association with mild/moderate OA (OR 1.4, 95% CI 0.4-4.7). By contrast, only 22% of men aged 45-54 with severe OA had current pain, though in older age groups the proportions with pain were higher (54-70%). Hip pain is relatively infrequent in the general population compared with the published reports of other regional pain syndromes. Mild/moderate radiographic change is very frequent and not related to pain, whereas severe change is rare but strongly related. In younger males, severe radiographic change is much less likely to be associated with pain.
Content may be subject to copyright.
Rheumatology 2004; 1 of 5 doi:10.1093/rheumatology/keh458
Association between pain in the hip region and
radiographic changes of osteoarthritis: results from
a population-based study
F. Birrell
, M. Lunt
, G. Macfarlane
and A. Silman
Objectives. The relationship between hip pain and radiographic change in the population is unclear due to lack of agreed
definition for hip pain and difficulties in obtaining radiographs from asymptomatic random samples. Our objective was to assess
the relationship between hip pain and radiographic change in osteoarthritis (OA) in a population sample aged over 45.
Methods. One thousand and seventy-one responders to a postal questionnaire using a recently validated approach to defining
hip pain were stratified into hip pain-positive and -negative groups and samples of each were X-rayed and scored for OA using
both minimum joint space and the Croft score. The association between pain and X-ray score was estimated, weighting back to
the age and gender distribution of the original population.
Results. Hip pain prevalence was 7% in males and 10% in females. Severe OA was present in 16% of those with and 3% of
those without pain. Adjusting for age and gender, there was a very strong association of pain with severe OA [odds ratio (OR)
17.4, 95% confidence interval (CI) 3.0–102], but no association with mild/moderate OA (OR 1.4, 95% CI 0.4–4. 7). By
contrast, only 22% of men aged 45–54 with severe OA had current pain, though in older age groups the proportions with pain
were higher (54–70%).
Conclusions. Hip pain is relatively infrequent in the general population compared with the published reports of other regional
pain syndromes. Mild/moderate radiographic change is very frequent and not related to pain, whereas severe change is rare but
strongly related. In younger males, severe radiographic change is much less likely to be associated with pain.
Regional pain syndromes such as anterior knee pain are very
commonly reported in general population surveys [1, 2]. Although
in the majority of those subjects reporting pain there is considered
to be no underlying pathology, in clinical practice the reporting of
such pain is frequently a signal for radiographic examination to
exclude the presence of underlying degenerative disease as the
source of the pain. In population-based epidemiological studies,
any associations between pain reporting (for example, of the knee)
and the presence of osteoarthritic changes have been weak [3].
Pain in the hip region appears to be less common than other
regional pain syndromes [4]. Hip pain is, however, important
for the affected individual as it impacts on key functions, such as
walking. The importance of hip pain for health-care providers
results from its association with osteoarthritis (OA) and the
potential need for joint replacement. Hip OA is the most frequent
indication for hip arthroplasty [5] and unremitting pain the most
important clinical determinant of need for surgery [6]. The ‘hip’,
however, is a difficult region to define topographically compared
with, for example, the shoulder or knee. Referred pain from the
back and disorders of structures in and around the inguinal
and pelvic areas all might present with pain in similar areas to
that resulting from true hip disease. Similarly, compared with
more superficial joints, subjects have difficulty in localizing the
hip as the source of their pain. Indeed, there are no well-accepted
definitions of hip pain for epidemiological studies.
We have recently shown that the optimal definition of hip pain is
one that requires the subject both to use the word ‘hip’ in referring
to the site of their pain in addition to indicating the presence of
pain in the ‘bathing trunk’ area on a validated preshaded manikin
[7]. Such a stringent definition demonstrated much stronger
associations with indicators of hip disease, such as restriction in
movement and health-care utilization, than less rigid definitions
requiring either just the verbal or just the manikin definition [8].
However, the strength of the relationship between radiographic
change and hip pain in the general population is not known. Such
studies require the radiographic investigation of asymptomatic
subjects and, for this reason, there are few data. We have therefore
investigated the relationship between radiographic damage and hip
pain in a large population sample. We have specifically addressed
two related questions: (i) given the presence of radiographic
change, how frequent is hip pain? and (ii), given the presence of
hip pain, how frequent is radiographic change? Thus, we wanted to
determine from the first question what proportion of severe OA,
for example, would be missed by consideration of those only
with current hip pain; and from the second question the value
of undertaking a radiograph in those with pain.
This was a two-stage population screening survey: subjects
completed a questionnaire asking about hip pain, and samples
of those with and without pain were invited for radiographic
Correspondence to: A. Silman:
arc Epidemiology Unit and
Unit of Chronic Disease Epidemiology, School of Epidemiology and Health Sciences, Manchester University Medical School,
Manchester M13 9PT, UK.
Present Address: University of Newcastle, Cookson Building, Framlington Place, Newcastle NE2 4NH, UK.
Submitted 5 July 2004; revised version accepted 30 September 2004.
Rheumatology ß British Society for Rheumatology 2004; all rights reserved
Rheumatology Advance Access published November 9, 2004
by guest on June 4, 2013 from
assessment. Associations between pain and OA were then
calculated based on weighting the X-ray results of those
participating in the second phase to the population that were
initially sent a questionnaire.
The sampling frame was the population listing from a general
practice population in the south of Manchester and has been
described in detail elsewhere [8]. This investigation was restricted
to subjects aged over 45, and a total of 1496 subjects were selected
for mailing a questionnaire.
Ascertainment of hip pain
The presence of current hip pain was determined using a postal
questionnaire. Two questions were used to determine the occur-
rence of hip pain. The subjects were asked (i) if they had had pain
in the hip for a period lasting more than 24 h in the previous
1 month, and (ii) to indicate on a manikin with a preshaded bathing-
trunk [7] area if they had had pain in that area during that period.
A positive respondent was one who reported hip pain using both
criteria. Subjects not responding to the questionnaire were sent a
postcard reminder within 2 weeks and a further questionnaire, if
necessary, after a further 2 weeks. The questionnaire also collected
data on a number of other aspects of hip pain and general health.
Radiographic follow-up
Random samples of those reporting and not reporting hip pain
were invited to attend a local hospital for a pelvic radiograph.
An anteroposterior pelvic film was taken in a standardized fashion
at a single centre. The X-rays were read blind to pain group by two
readers and graded using both the Croft modification of the
Kellgren and Lawrence (K&L) grading system [9]. The minimum
joint space (MJS) was also measured using a ruler, as previously
described by Croft et al. [9]. For the purposes of analysis, the scores
were stratified into three groups: (i) subjects with no OA (defined
as a K&L grade of <2 and MJS >2.5 mm); (ii) subjects with
mild to moderate OA (defined as a K&L score of at least 2 or
MJS <2.5 mm but not satisfying criteria for severe OA); and
(iii) subjects with severe OA (defined as a K&L score of at least 4 or
MJS <1.5 mm).
The subjects invited for radiographic investigation were not a
random sample of the original population but were weighted
towards studying a greater proportion of hip pain-positive
compared with hip pain-negative subjects. Further, both age and
gender were strongly related to the presence of any radiographic
change. Thus, for the purposes of analysis, the subjects were
stratified by age (in 10-yr age groups) and gender. We therefore
assumed that in each of the two pain groups the distribution of
radiographic changes in those studied was the same as that in those
subjects with the same age and gender profile, who answered the
questionnaire but were not selected or attended for X-ray. We used
the sampling weights for these two variables to estimate the
population occurrence of radiographic change. The data are thus
presented first as the estimated population prevalence of radio-
graphic change in subjects with and without pain, and secondly as
the estimated population prevalence of hip pain in subjects with
and without radiographic change. The confidence intervals (CIs)
for the population prevalences were calculated using the ‘svytab’
procedure in Stata 8.0 (Stata Corporation, College Station, TX,
USA), which uses a standard formula for calculating the standard
error of a prevalence in a two-stage sampling design such as this
[10]. To examine the influence of pain on X-ray grade, logistic
regression analyses were undertaken, adjusting for age and
stratified by gender, where appropriate.
The study was approved by the Local Research Ethics
Committee and written subject consent was obtained.
A total of 1496 subjects were mailed a questionnaire and, after the
two reminders, completed questionnaires were received from 1071.
A further 123 were notified as being sent to the wrong address.
Thus, the final adjusted response rate of those receiving the
questionnaire was 78%. The responders comprised 556 males and
515 females. The age- and gender-specific hip pain prevalences are
shown in Table 1. Overall, the prevalence was 6.8% in the males
and 10.3% in females. As shown, the prevalence was higher in
females at all ages except for those over the age of 75. A total of 82
subjects with hip pain and 308 without hip pain were invited
to attend for radiographic screening (women aged <50 were not
invited), of whom 56 (68%) and 147 (48%), respectively, attended.
An analysis within each pain group, comparing those who
attended for X-ray with those who did not, showed no evidence
of any participation bias in relation to the severity indicators
derived from the questionnaire. Thus in the hip pain group,
compared with those who did not, those who attended for X-ray
had similar visual analogue pain scores as well as similar
proportions of those using analgesics and requiring a walking
stick for their pain.
The distributions of radiographic score between those with and
without pain are shown in Table 2. There was a marked difference
between the two groups, as expected (
¼ 12.9, P ¼ 0.002). The
frequency of severe change was substantially larger in the group
with pain (16 vs 3%), and the absence of change was more common
in those without pain. However, mild/moderate OA was very
common in this population, with an equal high frequency of such
changes in both those with and without pain.
Age and gender were expected to have powerful effects on the
likelihood of radiographic change. Indeed, there were substantial
differences in the occurrence of radiographic change (independent
of pain frequency) between the genders and with age. Allowing
for the proportions with and without hip pain, the estimated
population prevalence of radiographic change by age and gender,
together with their 95% CIs, are shown in Table 3. These data
show that severe change was exceptionally rare in women at
TABLE 1. Prevalence of hip pain by age and gender
Men Women
Age group (yr) n Hip pain % n Hip pain %
45–54 220 10 4.6 227 22 9.7
55–64 169 12 7.1 140 14 10.0
65–74 117 7 6.0 95 12 12.6
75–84 50 9 18.0 53 5 9.4
TABLE 2. Frequency of radiographic change by presence/absence of pain
Radiographic severity
n (%)
Mild/moderate OA
n (%)
Severe OA
n (%)
No pain (n ¼ 147) 60 (41) 83 (56) 4 (3)
Pain (n ¼ 56) 16 (29) 31 (55) 9 (16)
2of5 F. Birrell et al.
by guest on June 4, 2013 from
all ages. Further, and unexpectedly, there was very little influence
of age on the occurrence of OA in men. It should be noted,
however, that these prevalences, once stratified by age and gender,
are based on very small numbers and as a result the CIs are wide.
The estimated prevalences of radiographic change in the
population were then stratified by pain status (Table 4). Women
were excluded from this analysis, given the virtual absence of
severe OA from this group. The data show that in each age group
those men with pain were substantially more likely to have severe
OA, with no influence on the likelihood of mild to moderate OA.
A weighted multinomial logistic regression analysis was under-
taken, adjusting for age, and this showed that the odds ratio (OR)
for mild/moderate OA in those with pain was 1.4 (95% CI 0.4–4.7),
with a much greater association with severe OA (OR 17.4, 95%
CI 3.0–102).
The final analysis was to evaluate the estimated population
prevalence of hip pain in those with and without evidence of OA
(Table 5). As discussed above, despite the higher prevalence of
pain in the women, there were virtually no women in this sample
with severe OA. In men, hip pain was more likely to be reported in
those with severe OA, but not by those with mild OA. Hip pain
was much less frequent in young men with severe radiographic
change (estimated prevalence 22%) and much higher in the other
age groups. The age-adjusted ORs for reporting pain in those with
mild to moderate OA and for those men with severe OA are the
same as above. The data for women, by contrast, do show an
association between mild to moderate OA and pain: OR 2.8, 95%
CI 0.94–8.6.
In summary, these data have highlighted that the frequency of hip-
region pain as defined in the community is low compared with
other regional pain syndromes, such as those affecting the knee
[1, 2]. The criteria for hip pain used were stringent, though, as
others have shown, the prevalence of hip pain, using a broader-
based question, was much higher. Thus, a study from Oxford [4]
in subjects over 65 revealed a prevalence of 19%, approximately
twice that observed in the same age group in the present study.
Similarly, the frequency of severe radiographic change in the
population is low, especially in women, whereas the frequency of
mild to moderate OA changes are more common in this age group
than a ‘normal’ X-ray appearance. The major findings relate to the
limited association between pain and X-ray. As an example,
despite an obvious relationship between severe change and pain in
males, we estimate that 1 in 20 men aged 45–54 without current hip
pain have severe radiographic OA. Examining the results the other
way round showed that important proportions of men, especially
in the youngest age group investigated (45–54), with severe
radiographic OA do not have current pain. By contrast, there
is no important relationship between current pain and milder
forms of OA.
There are a number of limitations in interpreting these
data. First, and most importantly, the numbers in each age and
gender group with X-ray data are small. Age and gender did have
substantial influences on both the occurrence of radiographic
change and probably the relationship between pain and OA.
The number of individuals in this community survey who were
X-rayed was too small to provide robust estimates in the
age–gender groups, and such strata-specific proportions are subject
TABLE 4. Estimated prevalence of radiographic damage by hip pain status: men
No pain Pain
Age group (yr) None Mild Severe None Mild Severe
45–54 34 (8, 74) 61 (24, 89) 5 (1, 33) 23 (3, 76) 45 (10, 85) 33 (6, 78)
55–64 53 (27, 77) 47 (22, 73) 1 (0, 6) 38 (12, 74) 38 (12, 74) 24 (5, 64)
65–74 56 (29, 80) 42 (19, 70) 1 (0, 7) n/a 71 (29, 94) 29 (6, 71)
75–84 44 (27, 63) 53 (34, 71) 3 (1, 13) 44 (14, 80) 30 (7, 71) 26 (6, 67)
Data are % (95% CI). n/a, numbers too small for calculation.
TABLE 3. Estimated (weighted) population prevalence of radiographic change
Radiographic severity
Men Women
Age group (yr) None Mild Severe None Mild Severe
45–54 33 (9, 72) 60 (25, 88) 7 (1, 30) 45 (23, 70) 55 (30, 77) 0
55–64 52 (27, 75) 46 (23, 71) 2 (1, 8) 33 (19, 50) 67 (50, 81) 0
65–74 53 (28, 77) 45 (21, 70) 3 (1, 9) 55 (31, 78) 43 (21, 68) 1 (0, 9)
75–84 35 (13, 67) 52 (35, 69) 5 (2, 12) 28 (7, 67) 72 (33, 93) 0
Data are % (95% CI).
TABLE 5. Estimated (weighted) prevalence of hip pain in subjects with
and without radiographic damage
Prevalence of hip pain: % (95% CI)
Age group (yr) None Mild Severe
45–54 3 (0, 28) 3 (1, 17) 22 (2, 84)
55–64 5 (1, 19) 6 (1, 21) 70 (12, 98)
65–74 n/a 10 (3, 28) 67 (11, 97)
75–84 22 (5, 64) 6 (3, 37) 54 (6, 95)
45–54 n/a 15 (5, 38) n/a
55–64 18 (7, 38) 5 (2, 15) n/a
65–74 4 (1, 19) 20 (7, 44) n/a
75–84 n/a 14 (4, 44) n/a
n/a, numbers too small for calculation.
Hip pain and radiographic change 3of5
by guest on June 4, 2013 from
to wide CIs. It is, however, not easy to obtain pelvic X-rays from
true population samples, which is why alternative strategies have
been used, such as reading films from intravenous urograms [9].
Secondly, and perhaps surprisingly, we found only one woman
from the 109 with X-rays who had severe OA, and as a
consequence we are unable to usefully comment on the relation-
ship between pain and severe OA in women. Clinical experience
demonstrates that severe hip OA clearly exists in women and
the virtual absence of this state in the current cohort might reflect
the population scarcity of this grade of OA, or possibly a selective
non-response or non-participation of those women with the worst
disease. The latter seems intuitively unlikely as typically it is
those with the relevant health problem who are more likely
to respond to survey participation.
Thirdly, the nature of the study design meant that hip pain
subjects were more likely to be sampled for radiological examina-
tion. As one aim was to ascertain the relationships between pain
and X-ray change in the whole population, we assumed that that
the former would be the same between those who were and were
not X-rayed. It is difficult to be certain about the correctness of
this assumption, though analysis of certain characteristics related
to hip pain severity in those with hip pain who were and were not
X-rayed does not suggest any important selection bias.
The response rates to the questionnaire were high and should
not have influenced the external validity of these results. The
participation rates for those selected for X-ray were lower and
selectively different when those with and without pain were
compared. It is obviously difficult to encourage those who were
pain-free to attend for radiographic examination. It is possible that
those who did may have selected themselves on characteristics
such as previous injury [11], family history [12] or obesity [13],
all of which might have resulted in a bias towards those with
OA changes. The study population was also drawn from a
single general practice population, and again the associations
between hip pain and X-ray change may not be applicable to other
groups, which might have a different underlying prevalence of
disorders leading to either hip pain or OA. Thus, farming com-
munities have been shown to have a higher prevalence of OA
hip [14].
There are a number of strengths of the present study. First,
we used a validated definition for hip pain which has been
demonstrated to have greater construct validity with measures
of hip disease than definitions relying either on the use of the
word ‘hip’ or on a pain manikin alone [9]. Secondly, the X-rays
were taken and read in a standardized and blinded fashion; we
have previously reported on our reliability of reading hip X-rays
[7]. Thirdly, the population answering the first questionnaire
was large, with a high response. It was also possible within the
present study to obtain a number, albeit limited, of X-rays on
those with pain-free hips, a task of increasing difficulty as
both ethical and population concerns about X-rays increase in
The prevalence of mild to moderate OA changes was, as noted
above, very high and indeed such change was more common than
a ‘normal’ radiograph. Further, such changes were not associated
with pain. The major conclusion from such observations is that
these degrees of radiographic change, although they might
represent an underlying anatomical change, are perhaps inappro-
priately considered as representing the disease state of clinical OA.
Therefore, the term ‘mild–moderate OA’ to describe such changes
is probably misleading.
It was interesting to note that the likelihood of reporting pain,
given the presence of severe OA, was substantially less likely in
younger men. This observation would add weight to the concept
that other factor(s) other than the degree of radiographic damage
contribute to pain. One explanation, impossible to test in a cross-
sectional study, is that age is a surrogate for ‘disease duration’
and that the younger men have had changes for a shorter period,
and it is the longevity of the change that contributes to pain.
This, however, would not explain why the rates of pain are not
highest in the oldest ages. Ageing itself may be accompanied by an
increase in pain perception, although in population surveys the
increased reporting of musculoskeletal pain with ageing is only
modest [15].
As noted in the Introduction, there are few studies with which
to compare these results. A study of intravenous urograms
from 1315 men aged 60–75 was used to provide a population
surrogate for identifying the frequency of different aspects of
radiographic hip OA. In total, 29% of a subset of 759 of these men,
who provided information, reported ever having had hip pain,
though again it was only in those with radiographic appearances
at the extreme (2%) end of the radiographic severity spectrum
that there was an association between pain and radiographic
feature [9].
There are, however, some interesting messages that emerge.
First, it would be inappropriate to conclude that an elderly patient
with hip region pain is inevitably likely to have OA. Secondly,
even severe radiographic change is relatively infrequently accom-
panied by continuing hip pain, and it is important to be cautious
before linking the pain with the X-ray. Thirdly, the majority of
younger male subjects in the community with severe OA will be
pain-free, and in subjects with other indicators of hip disease,
such as known childhood hip disorder, prior injury or limitation in
movement, severe OA could still be present.
This study was funded by the UK Arthritis Research Campaign
(arc) and F.B. was an arc research training fellow in
epidemiology. We are grateful to Dr Coope (The Waterhouse,
Bollington Medical Practice) and Dr Sanders (Cheadle Medical
Practice) and their staff for access to their patient population.
The survey was coordinated by Liz Nahit, who also assisted in
the reading of the radiographs.
The authors have declared no conflicts of interest.
1. Mcalindon TE, Cooper C, Kirwan JR et al. Knee pain and disability
in the community. Br J Rheumatol 1992;31:189–92.
2. O’Reilly SC, Muir KR, Doherty M. Knee pain and disability in the
Nottingham community: association with poor health status and
psychological distress. Br J Rheumatol 1998;37:870–3.
3. Hannan MT, Felson DT, Pincus T. Analysis of the discordance
between radiographic changes and knee pain in osteoarthritis of the
knee. J Rheumatol 2000;27:1513–7.
4. Dawson J, Linsell L, Zondervan K et al. Epidemiology of hip and
knee pain and its impact on overall health status in older adults.
Rheumatology 2004;43:497–504.
5. NIH Consensus Development Panel on Total Hip Replacement. Total
hip replacement. JAMA 1995;273:1950–6.
Key messages
There is a limited relationship between
the presence of hip pain and the degree of
radiographic change in the community.
Severe hip OA in younger men is
frequently pain-free.
4of5 F. Birrell et al.
by guest on June 4, 2013 from
6. Hadorn DC, Holmes AC. The New Zealand priority criteria project.
Part 1: overview. Br Med J 1997;314:131–4.
7. Birrell F, Croft P, Cooper C, Hosie G, Macfarlane GJ, Silman A.
Radiographic change is common in new presenters in primary
care with hip pain. PCR Hip Study Group. Rheumatology 2000;39:
8. Birrell F, Lunt M, Macfarlane G et al. Defining hip pain for
population studies. Ann Rheum Dis 2004. In press.
9. Croft P, Cooper C, Wickham C et al. Defining osteoarthritis of the hip
for epidemiologic studies. Am J Epidemiol 1990;132:514–22.
10. Cochrane WG. Sampling techniques. 3rd edition. New York, NY:
John Wiley & Sons, 1977.
11. Felson DT. An update on the pathogenesis and epidemiology of
osteoarthritis. Radiol Clin North Am 2004;42:1–9.
12. MacGregor AJ, Antoniades L, Matson M, Andrew T, Spector TD.
The genetic contribution to radiographic hip osteoarthritis in women:
results of a classic twin study. Arthritis Rheum 2000;43:2410–6.
13. Gelber AC. Obesity and hip osteoarthritis: the weight of the evidence
is increasing. Am J Med 2003;114:158–9.
14. Croft P, Coggon D, Cruddas M et al. Osteoarthritis of the hip an
occupational disease in farmers. Br Med J 1992;304:1269–72.
15. Symmons DPM. Population studies of musculoskeletal morbidity.
In: Silman AJ, Hochberg MC, eds. Epidemiology of the rheumatic
diseases, 2nd edition. Oxford, UK: Oxford University Press, 2001.
Hip pain and radiographic change 5of5
by guest on June 4, 2013 from
... Both systems are inherently subjective [4], contributing to widely varying rHOA prevalence estimates that range from 0.9-27% [5], and though atlases help to reduce ambiguity they cannot prevent it entirely [6]. In addition, lower KL and Croft grades are poorly predictive of disease [7], and show weak and inconsistent associations with hip pain, calling into question their clinical relevance [8][9][10]. This likely reflects not only ambiguity and subjectivity of scoring, but also limitations in how these scores are derived. ...
... There are some similarities in comparing our study with previous studies based on KL grading of radiographs. For example, a primary care study (n ¼ 1496) found an OR of 17.4 (95% CI 3, 102) for hip pain in those with KL grade 4, compared with an OR of 11.8 (8.5-16.4) for hip pain in those with grade 4 using our DXA-based classification [8]. Previous studies found KL grade >2 to be associated with a HR of 12.9 and OR from 13.8-30.6 ...
Full-text available
Objective Conventional scoring methods for radiographic hip osteoarthritis (rHOA) are subjective and show inconsistent relationships with clinical outcomes. To provide a more objective rHOA scoring method, we aimed to develop a semi-automated classifier based on dual-energy X-ray absorptiometry (DXA) images, and confirm its relationships with clinical outcomes. Methods Hip DXAs in UK Biobank (UKB) were marked up for osteophyte area from which acetabular, superior and inferior femoral head osteophyte grades were derived. Joint space narrowing (JSN) grade was obtained automatically from minimum joint space width (mJSW) measures. Clinical outcomes related to rHOA comprised hip pain, hospital diagnosed OA (HES OA) and total hip replacement (THR). Logistic regression and Cox proportional hazard modelling were used to examine associations between overall rHOA grade (0–4; derived from combining osteophyte and JSN grades), and the clinical outcomes. Results 40 340 individuals were included in the study (mean age 63.7), of whom 81.2% had no evidence of rHOA, while 18.8% had grade ≥1 rHOA. Grade ≥1 osteophytes at each location and JSN were associated with hip pain, HES OA and THR. Associations with all three clinical outcomes increased progressively according to rHOA grade, with grade 4 rHOA and THR showing the strongest association [57.70 (38.08–87.44)]. Conclusions Our novel semi-automated tool provides a useful means for classifying rHOA on hip DXAs, given its strong and progressive relationships with clinical outcomes. These findings suggest DXA scanning can be used to classify rHOA in large DXA-based cohort studies supporting further research, with the future potential for population-based screening.
... Third, we could not evaluate hip pain because of the retrospective study design. Hip pain is a chief symptom of hip OA; however, the precise association between hip OA and pain remains unclear [37][38][39][40], and most individuals with hip pain do not have radiographic hip OA [38,41]. Thus, we believe that the evaluation of hip pain is not relevant to this study. ...
Full-text available
Background Lumbar fusion corrects spinal deformities and improves spinal complications. Hip osteoarthritis (OA) is strongly correlated with spinal mobility, and joint space narrowing of the hip after spinal fusion has gained attention. This study aimed to elucidate the effect of spinal fusion on hip joint space narrowing. Materials and methods We retrospectively examined 530 hips of 270 patients who underwent spinal surgery. All the patients underwent whole-spine radiography before and at the final follow-up. Patients were divided into three groups (N group: non-spinal fusion, S group: up to three interbody fusions, and L group: more than four interbody fusions). The rates of joint space narrowing, spinal parameters (sagittal vertical axis, thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence), and limb length discrepancy at the final follow-up were compared. A multilinear regression analysis was performed to identify the risk factors for the rate of joint space narrowing. Results The rate of joint space narrowing was significantly higher in the L group than in the N and S groups ( P < 0.001). No significant difference in the rate of joint space narrowing was observed between the N and S groups. Multiple linear regression analysis revealed that the number of fusion levels ( p < 0.05) and follow-up period ( p < 0.001) were independent risk factors for joint space narrowing. Spinal parameters at the final follow-up were not independent risk factors. Conclusions Long spinal fusion (more than four levels) led to significantly greater joint space narrowing of the hip than short (up to three levels) or no fusion. Spinal alignment did not affect joint space narrowing of the hip. Surgeons should be aware that more than four interbody fusions may result in worse joint space narrowing of the hip. Level of evidence IV, retrospective study
... Semi-quantitative grading of hip OA can be done using Kellgren-Lawrence (KL) [8] or Croft [9] scoring which examine the presence and severity of radiographic characteristic features, including joint-space narrowing (JSN), osteophytes, subchondral scleroisis, and cysts. These criteria are inherently subjective [10], making clinical application difficult [11][12][13]. Although severity grading is traditionally performed by manual inspection of standard radiographs, Yoshida et al. [17] found that this could be performed as accurately using DXA scans. ...
Osteophytes are distinctive radiographic features of osteo-arthritis (OA) in the form of small bone spurs protruding from joints that contribute significantly to symptoms. Identifying the genetic determinants of osteophytes would improve the understanding of their biological pathways and contributions to OA. To date, this has not been possible due to the costs and challenges associated with manually outlining osteophytes in sufficiently large datasets. Automatic systems that can segment osteophytes would pave the way for this research and also have potential clinical applications. We propose, to the best of our knowledge, the first work on automating pixel-wise segmentation of osteophytes in hip dual-energy x-ray absorptiometry scans (DXAs). Based on U-Nets, we developed an automatic system to detect and segment osteophytes at the superior and the inferior femoral head, and the lateral acetabulum. The system achieved sensitivity, specificity, and average Dice scores (±std) of (0.98, 0.92, \(0.71\pm 0.19\)) for the superior femoral head [793 DXAs], (0.96, 0.85, \(0.66\pm 0.24\)) for the inferior femoral head [409 DXAs], and (0.94, 0.73, \(0.64\pm 0.24\)) for the lateral acetabulum [760 DXAs]. This work enables large-scale genetic analyses of the role of osteophytes in OA, and opens doors to using low-radiation DXAs for screening for radiographic hip OA. KeywordsComputational anatomyU-NetsOsteophytes segmentationOsteophytes detectionAutomated osteoarthritis risk assessment
... In this same study, those with worsening hip structure also had less hip extension, although not significantly so. The presence of structural damage is not tightly linked to hip pain (Birrell et al., 2005;Heerey et al., 2018;Park et al., 2021). Worsening pain has been associated with limited hip extension and external rotation during walking in females with mild to moderate hip OA (Tateuchi et al., 2019). ...
Full-text available
Background: Individuals with hip osteoarthritis (OA) commonly walk with less hip extension compared to individuals without hip OA. This alteration is often attributed to walking speed, structural limitation, and/or hip pain. It is unclear if individuals who are at increased risk for future OA (i.e., individuals with pre-arthritic hip disease [PAHD]) also walk with decreased hip extension. Objectives: (1) Determine if individuals with PAHD exhibit less hip extension compared to individuals without hip pain during walking, and (2) investigate potential reasons for these motion alterations. Methods: Adolescent and adult individuals with PAHD and healthy controls without hip pain were recruited for the study. Kinematic data were collected while walking on a treadmill at three walking speeds: preferred, fast (25% faster than preferred), and prescribed (1.25 m/s). Peak hip extension, peak hip flexion, and hip excursion were calculated for each speed. Linear regression analyses were used to examine the effects of group, sex, side, and their interactions. Results: Individuals with PAHD had 2.9° less peak hip extension compared to individuals in the Control group ( p = 0.014) when walking at their preferred speed. At the prescribed speed, the PAHD group walked with 2.7° less hip extension than the Control group ( p = 0.022). Given the persistence of the finding despite walking at the same speed, differences in preferred speed are unlikely the reason for the reduced hip extension. At the fast speed, both groups increased their hip extension, hip flexion, and hip excursion by similar amounts. Hip extension was less in the PAHD group compared to the Control group ( p = 0.008) with no significant group-by-task interaction ( p = 0.206). Within the PAHD group, hip angles and excursions were similar between individuals reporting pain and individuals reporting no pain. Conclusions: The results of this study indicate that kinematic alterations common in individuals with hip OA exist early in the continuum of hip disease and are present in individuals with PAHD. The reduced hip extension during walking is not explained by speed, structural limitation, or current pain.
... Chronic hip pain is a prevalent and functionally limiting symptom, which may be due to osteoarthritis, rheumatoid arthritis, osteonecrosis, infectious coxarthrosis, and post-total hip arthroplasty pain [1]. Conservative management includes physical therapy, topical modalities, and nonsteroidal antiinflammatory medications. ...
Full-text available
Chronic hip pain can be treated with physical therapy, oral medications, injections, and, definitively, total hip arthroplasty. Enough patients have contraindications to and refractory pain even after total hip arthroplasty, that there is a need to develop alternative managements for this disabling condition. This article examines the state of hip radiofrequency ablation literature including relevant anatomy, patient selection, and treatment outcomes.
Total hip arthroplasty (THA) is a surgical procedure performed when the patient’s hip joint is worn or damaged. The main aim of the surgery is to reduce the pain experienced by the patients while simultaneously increasing their potential range of motion, thus allowing them to return to their daily activities without experiencing severe pain that could potentially interfere with their performance. There are a variety of approaches that could be employed for THA, and the main differences involve the positioning of the patient on the operating table, as well as the methodology used to access the hip joint, which subsequently leads to distinct positive outcomes alongside negative impacts. In this work, we review research literature for each approach and highlight the strengths as well as the weaknesses of each individual approach.
Purpose The purpose of this systematic review was to assess the indications, outcomes and complications of hip arthroscopy in individuals 50 years of age or older over the past five years. Methods The electronic databases PUBMED, MEDLINE, and EMBASE) were searched on March 3rd, 2022, for studies assessing the use of primary hip arthroscopy for patients aged 50 years or older from the past five years. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively. Results Overall, 17 studies were included, consisting of 6696 patients (37.5%) with a mean age of 61.4 ± 5.0 years and a median follow-up of 24 months (range, 1.4-70.1) Indications for hip arthroscopy in patients aged 50 years or older were unspecified/undefined (93.8%), mixed pathology (i.e., combined femoroacetabular impingement [FAI], labral tear, osteoarthritis, etc.) (2.7%), and FAI (2.6%). Eleven studies demonstrated significant improvement in functional outcome scores from baseline to final follow-up. Of the six studies that compared outcomes across multiple age groups, three demonstrated significantly worse functional outcomes and two demonstrated significantly higher rates of conversion to THA for older patients compared to younger patients. Lastly, the overall complication rates ranged from 0 to 38.3%. The rate of conversion to THA ranged from 0 to 34.6%, occurring between 6 and 60 months post-operatively. Conclusions Hip arthroscopy for patients aged 50 years or older yields significant improvements in patient-reported outcomes post-operatively compared to baseline, with a moderate rate of conversion to THA (range, 0 to 34.6%). Clinicians should consider patient history (e.g., imaging, comorbidities, etc.,) and values when electing for hip arthroscopy in the older population.
Lateral femoral and lateral obturator sensory nerves radiofrequency (RF) ablation provides a significant, clinically meaningful long‐term improvement in pain scores for patients with advanced osteoarthritis, avascular necrosis or even previous arthroplasty of the hip joint. Currently, hip denervation techniques include conventional and cooled RF denervation using various approaches: anterior, lateral, and inferior. The use of sensory stimulation before RF lesioning to improve accuracy is required. A significant amount of intraprocedural pain was experienced by most of the patients undergoing hip RF denervation using such an approach. Loss of sensation in the cutaneous distribution of the femoral nerve and obturator nerve may be seen. Neuritis and bleeding are rare and pain at the denervation site infrequently present. Ablation of nerves that have both sensory and motor components should only be performed where motor function loss is unimportant to avoid adverse clinical consequences.
Full-text available
Background: The diagnosis of hip osteoarthritis (OA) is often based on clinical symptoms, such as pain and stiffness, and radiographic features. However, the association between hip pain and hip radiographic OA (ROA) remains uncertain. Aim: To examine the association between hip pain and hip ROA. Design and setting: Cross-sectional analysis of a Dutch cohort, the Cohort Hip and Cohort Knee (CHECK) study. Method: The participants (aged 45-65 years) had all experienced hip and/or knee pain for which they had not had a prior consultation or were within 6 months of their first consultation with a GP. Using weight-bearing anteroposterior pelvis radiographs, definite and early-stage hip ROA were defined as Kellgren and Lawrence grade ≥2 and ≥1, respectively. Presence of ROA and pain was assessed in the hips of all participants. The association between hip pain and ROA was assessed using generalised estimating equations. Results: The prevalence of definite ROA was 11.0% (n = 218/1982 hips), with prevalence in painful and pain-free hips of 13.3% (n = 105/789) and 9.5% (n = 113/1193), respectively. Prevalence of early-stage hip ROA was 35.3% (n = 700/1982), with prevalence in painful and pain-free hips of 41.2% (n = 325/789) and 31.4% (n = 375/1193), respectively. Compared with pain-free hips, the odds ratio painful hips was 1.51 (95% confidence interval [CI] = 1.16 to 1.98) for definite ROA and 1.47 (95% CI = 1.24 to 1.75) for early-stage ROA. Conclusion: Hip pain was associated with definite and early-stage hip ROA, yet the overall ROA prevalence was modest and the prevalence among pain-free hips was substantial. Therefore, radiographs provided little assistance with help to identify patients with hip OA among patients who recently presented with hip or knee complaints.
Purpose of review: The introduction of ultrasound guidance in interventional pain management leads to the development of new interventional pain management techniques. Ultrasound-guided (UG) interventional pain management is rapidly developing and increasingly more commonly used, due to its many advantages over traditional radiologic imaging modalities. This review will summarize recent literature around novel interventional pain techniques with ultrasound guidance published over the last 18 months. Recent findings: Many new interventional pain management methods have been described in the last few years in the literature. The use of ultrasonography in interventional pain management played a crucial role in these developments. This review includes newly described interventional methods in the literature. The review particularly focussed on the methods that are used to treat the pain in the hip, shoulder, knee, and lumbar area. These new techniques hold promise for significant improvements in the efficacy and safety of interventional pain management. Summary: There have been many innovations in UG interventional procedures, however, some of them require more rigorous validation before their widespread use.
Full-text available
In order to investigate the strength of any relationship between knee pain and disability, a postal questionnaire was sent to 2102 men and women aged over 55 registered at a general practice in Bristol. A response rate of 80.6% was achieved at second reminder. Knee pain was common particularly in women (27.6% overall). Disability was also more frequently reported in women (P less than 0.05) and rose with increasing age. Respondents with knee pain had significantly more disability relating to upper as well as lower limb activities (P less than 0.05).
Full-text available
To determine the prevalence of radiographic osteoarthritis in subjects with hip pain newly presenting to primary care. The study was cross-sectional in design, set in 35 general practices across the UK. It included 195 men and women aged 40 yr and over (median 63 yr) presenting with a new episode of hip pain. Hip radiographs were scored for minimum joint space (MJS) and overall-Croft's modification of the Kellgren and Lawrence (Croft)-grade of osteoarthritis. In all, definite evidence of radiographic change in the painful joint was common: Croft grade > or =2 in 44%, > or =3 in 34%. MJS of 2.5 mm or less was seen in 30% of whom half were below 1.5 mm. There were no significant gender differences in radiographic severity. Radiographic change is common in patients newly presenting with hip pain and many already have advanced disease.
Full-text available
To obtain prevalence rates of hip and knee pain in elderly people and compare combinations of symptoms with overall health status. We performed a cross-sectional postal survey of a random sample of 5500 Oxfordshire residents aged 65 yr and older. Prevalence estimates were based on the screening question: 'During the past 12 months, have you had pain in or around either of your hip/knee joints on most days for one month or longer?' Overall health status was assessed with the SF-36 questionnaire. The response rate was 66.3% (3341/5039 eligible people), and was highest (approximately reverse similar 72%) for the 65-74 yr age-group. The percentage reporting hip pain was 19.2% [95% confidence interval (CI) 17.9-20.6], and 32.6% (95% CI 31.0-34.3) reported knee pain. The percentage reporting hip and knee pain was 11.3%, and 40.7% reported hip or knee pain. Less than half (48%) of the symptomatic respondents had unilateral problems affecting one hip or knee joint only. SF-36 scores worsened as the number of symptomatic hip and knee joints increased (P<0.001 for physical function, physical role limitation and bodily pain). Patterns of hip and knee symptoms are complex in older people. Amongst the symptomatic, most have more than one hip/knee affected. This has implications for treatment and health status measurement. In the absence of hip and knee symptoms, general health status scores of elderly people are similar to those of people aged under 65 yr.
To test the hypothesis that farmers are at high risk of hip osteoarthritis and to investigate possible causes for such a hazard. Cross sectional survey. Five rural general practices. 167 male farmers aged 60-76 and 83 controls from mainly sedentary jobs. All those without previous hip replacement underwent radiography of the hip. Hip replacement for osteoarthritis or radiological evidence of hip osteoarthritis. Prevalence of hip osteoarthritis was higher in farmers than controls and especially in those who had farmed for over 10 years (odds ratio 9.3, 95% confidence interval 1.9 to 44.5). The excess could not be attributed to any one type of farming, and heavy lifting seems the likely explanation. Manual handling in agriculture should be limited where possible. Consideration should be given to making hip osteoarthritis a prescribed industrial disease in farmers. There may be wider implications for the prevention of hip osteoarthritis in the general population.
The authors compared seven radiologic indices of hip osteoarthritis to establish which provided the best definition of the disease for epidemiologic purposes. Hip joints were assessed from intravenous urograms taken in a British hospital between 1982 and 1987 in 1,315 men aged 60-75 years. The indices examined were an overall qualitative grading of osteoarthritis, four measures of joint space, the maximum thickness of subchondral sclerosis, and the size of the largest osteophyte. Minimal joint space (i.e., the shortest distance between the femoral head margin and the acetabulum) was the index most strongly associated with other radiologic features of osteoarthritis. Among a subset of 759 men who answered a questionnaire about symptoms, the overall qualitative grading, minimal joint space, and thickness of subchondral sclerosis were the radiologic indices most predictive of hip pain. Within- and between-observer repeatability were tested in a subset of 50 subjects. Measures of joint space were more reproducible than other indices. These data suggest that, at least in men, minimal joint space is the best radiologic criterion of hip osteoarthritis for use in epidemiologic studies.
New Zealand restructured its health system in 1992 with the aim of achieving greater levels of assessment and accountability in the publicly funded health sector. A committee was established specifically to advise the minister of health on the kinds, and relative priorities, of health services that should be publicly funded. One of its projects has been to develop standardised sets of criteria to assess the extent of benefit expected from elective surgical procedures. These have been developed with the help of professional advisory groups using a modified Delphi technique to reach consensus. So far the committee has developed criteria for cataract surgery, coronary artery bypass grafting, hip and knee replacement, cholecystectomy, and tympanostomy tubes for otitis media with effusion. These criteria incorporate both clinical and social factors. Use of priority criteria to ensure consistency and transparency regarding patients' priority for surgery is required for access to a dedicated NZ$130m (pounds 57m; US$90m) pool of money, created to help eliminate surgical waiting lists and move to booking systems. The criteria will also be used in surgical outcome studies, currently in the planning phase.
To analyze cross sectional data from the National Health and Nutrition Examination Survey (NHANES I) concerning 3 indicators of osteoarthritis (OA) of the knee: radiographic evidence of structural damage, self-reported knee pain, and self-report of a diagnosis of arthritis at any joint by a physician. Analysis of NHANES I data for 6880 persons ages 25-74 in the United States. Radiographic stage 2-4 knee OA was found in 319 subjects (3.7%); only 47% of these individuals reported knee pain, and only 61% reported that a physician had told them that they had arthritis. Knee pain was reported by 1004 subjects (14.6%), only 15% of whom had radiographic stage 2-4 changes of OA, and 59% of whom reported having a diagnosis of arthritis by a physician. A report of arthritis diagnosed by a physician was given by 1762 subjects (25.6%), of whom only 11% had stage 2-4 radiographic knee OA and 34% reported knee pain. Substantial discordance exists in this population based study between radiographic OA of the knee versus knee pain, versus a diagnosis of arthritis by a physician. These phenomena may be important in the design of clinical research studies, as well as in criteria for OA.
To assess the genetic contribution to radiographic hip osteoarthritis (OA) by measuring the distribution of disease features in monozygotic (MZ) and dizygotic (DZ) twins. A population-based, cross-sectional study was conducted of 135 MZ and 277 DZ healthy female twin pairs, 50 years of age and older, who were recruited into the St. Thomas' UK Adult Twin Registry. Pelvic radiographs were read by a single observer who was blinded to the pairing and zygosity of the twins. The films were assessed for overall OA grade using a modification of the Kellgren and Lawrence scheme, and assessed for individual radiographic features. There was evidence of significant familial clustering for grade I and grade II OA changes, with an excess concordance in MZ twins compared with DZ twins, suggesting a genetic effect. The MZ versus DZ excess was also apparent for those classified as having more severe disease, although the number of pairs with these disease features was small. Familial clustering attributable to genetic factors was evident for joint space narrowing of <2.5 mm. Familial, but not genetic, clustering was seen for subchondral sclerosis. The number of pairs concordant for definite osteophytes in the sample was too low to assess this feature alone. These results translate into a significant heritability of 58% for OA overall and 64% for joint space narrowing. The heritability estimates decreased a little when the potential confounding influences of age, body mass index, and hip bone density were taken into account. Genetic factors have a significant contribution to OA at the hip in women and account for approximately 60% of the variation in population liability to the disease.