- What does rheumatoid arthritis feel like?
- What Rheumatoid Arthritis Feels Like…
- Overview – Arthritis
- Types of arthritis
- Hip Surgery for Rheumatoid Arthritis
- Considering Surgery
- Recovering from surgery
- Rheumatoid Arthritis Hip Pain Treatments That Work
- Determine the True Cause of Hip Pain to Inform Treatment Options
- Treating Bursitis and Iliotibial Band Syndrome in Hips vs. Tendinitis in Hips
- Depending on Pain Location, Injectable or Oral Medications May Help
- Stretches and Hot or Cold Therapies for Complementary Hip Pain Relief
- Pain-Relieving Topical Creams Help Hip Pain, Too
- Sit Less, Stand More to Improve Hip Pain and Other RA Symptoms
- Hip Arthritis
- How Rheumatoid Arthritis Affects the Hips
- Symptoms of Hip RA
- Diagnosing Hip RA
- Treating Hip RA
- Hip Replacement Surgery for Hip RA
- Key Takeaways
- 2. Case Presentation
What does rheumatoid arthritis feel like?
Without a doubt, I’ve heard the question “What does rheumatoid arthritis feel like?” more times and in more forms than anyone can even fathom. What that says to me is that there is a desire among people to truly understand what it is like to live with RA or another chronic illness day to day, on a long-term basis.
Next year will be the 30th anniversary of my rheumatoid arthritis. An auspicious anniversary to be sure, but I have lived through so much over the tenure of my illness that’s it’s difficult to put into words the full scope of my experiences. There has been a disgusting amount of pain and suffering, but there has also been an equally fantastic amount of learning, meeting people, sharing, and being honored.
I have contributed to Poet’s Corner before, and I always try to do something more on the artistic side, instead of just writing another blog. This time, for this Poet’s Corner, I’m going to do my best to answer the thing that people ask me most about my disease and describe what rheumatoid arthritis is like. It was surprisingly easy to come up with an answer. It’s half stream of consciousness, half allegory, and, hopefully, all evocative….
What Rheumatoid Arthritis Feels Like…
Having rheumatoid arthritis is like spraining all your joints at once and having someone wrap them all with tiny heating pads while they force you to move.
Fatigue, fatigue, fatigue. I’m so tired, all the time. I need more coffee. I need more caffeine pills. I can’t fucking sleep forever, either. Ten hours last night, what the Hell?? I can’t sleep my whole fucking life away. I wish I didn’t have to sleep at all. Bah.
I have to see my doctor for narcotics every 30 days. Fucking drug addicts, this is what they did to us legit users. Why do I have to get a script every single month, schlep into the city, and pay for a visit, because they find shyster docs who they pay cash for Oxycontin?? I had to fight my insurance company for a year and go before a judge to get the pills I need because some junkie snorted up his future. Now they want to limit the number of pills a pharmacy can get per month, regardless of the amount of scripts they have to fill? Wonderful. Disabled people screwed again.
God I’m so thirsty all the time. I don’t get it. I drink so much water I feel like I’m going to burst, and it’s doing nothing. I still wake up in the middle of the night and my tongue is stuck to my cheek. Ugh. How can someone who drinks enough water to pee 15 times a day still have dry mouth?
Hip hurting. Fear. Afraid it is wearing out after 20 years. It’s going to go soon. The doc said I don’t need to replace it all, only the top part. Of course, if the fucking doctor who screwed up my first hip but the old hip in, then I’m screwed. Scared. Angry. Frustrated.
Allison just came home from work. She works so damn hard every day, I can’t even qualify for a work at home job. Worthless. Inadequate. She knows she will probably be the only stable full time income and she still married me? She is so compassionate. Love. Admiration. My stupid disability check is a pittance. Embarrassment.
Ankle hurts. My foot hurts. Tried of walking on the side of my right foot. This botched ankle replacement was supposed to fix everything. Fury. Anger. Fist clenched. Foot hurts where the metatarsal bones have begun to poke out on the side. Goddamn this disease and everything with it. Now I have to schedule a second surgery for this ankle. Fuck. FUCK. FUCK!!!!!!!
I’m going to play so video games to relax. I hate doing it especially during the day when Allison works, but I have to unwind. I boot up the game and after 30 minutes, hands hurt. Fucking right thumb hurts now, can’t play any more. Defeat. Exasperation. Frustration. Mouse on a wheel. What’s the point?
I’ll write something, that is always a joy. Hands hurt. Don’t care. This blog came out great! It will be well-received, I know it. Man, why can’t make a ton of money writing? I mean I know I’m good at it. Wonder. Questions. I guess I will try to write another book, I know if I keep trying it will happen for me eventually. Optimism. Pride.
Alarm. Time to take my pills. Sigh. Fucking heart attack pills, fucking doctor stole 20% of my heart from me. Shouldn’t have cleared me for surgery. Extreme anger. Defibrillator installed. I literally gave part of my heart to this disease, what better allegory can there be? Pride in stoicism. Toughness. Ah, I can take it, I can fucking take anything this shit will throw at me, and keep on ticking. Never cry. Always stay positive. Fuck yeah. Superiority over the weak. Pride. Confidence.
Having chronic illness is like being hooked up to a torture device with a madman at the controls. A true madman, that is, not one that has a method, or an ethos, or a procedure. Someone who turns on the torture machine at will, whenever he feels like it. There’s no way to predict when or how it will happen. The uncertainty takes many years to master dealing with, and the fact you never know makes life with rheumatoid illness and other chronic diseases extremely difficult. More so than other, less unpredictable, diseases.
Time for bed. Another restless night. Back hurts. Foot hurts. Neck hurts. Fucking still have to get my teeth replaced, 60 thousand dollars I don’t have. Here we go with the air conditioner, ready to freeze me and make me suffer another night. Still better than sweating, I guess. Exasperation. Exhaustion. I’m sure I’ll wake up fatigued again tomorrow. Maybe I’ll take an extra dose of steroids tonight just so I can have a good day tomorrow. Yeah I will. Shame. Feeling of being scolded. Don’t care. I’ll read some. Pass out. iPad hits me in the head, wakes me up. Flash of anger. Subsides. Give up. Sweet sleep, where nothing hurts.
This is the best example I can give you of what goes on in my head (and body) on a daily basis. Having a chronic illness and the unpredictability of the disease is something that is almost indescribable, so that’s why when you ask one of us “what it’s like?” we have trouble answering. I hope this gives you some insight into the struggle, and also makes you realize that you might not be that different.
CreakyJoints wishes our good friend and featured blogger Dan Malito a speedy recovery as he heads into his latest ankle replacement surgery.
Types of arthritis
Osteoarthritis and rheumatoid arthritis are the 2 most common types of arthritis.
Osteoarthritis is the most common type of arthritis in the UK, affecting nearly 9 million people.
It most often develops in adults who are in their mid-40s or older.
It’s also more common in women and people with a family history of the condition.
But it can occur at any age as a result of an injury or be associated with other joint-related conditions, such as gout or rheumatoid arthritis.
Osteoarthritis initially affects the smooth cartilage lining of the joint. This makes movement more difficult than usual, leading to pain and stiffness.
Once the cartilage lining starts to roughen and thin out, the tendons and ligaments have to work harder.
This can cause swelling and the formation of bony spurs called osteophytes.
Severe loss of cartilage can lead to bone rubbing on bone, altering the shape of the joint and forcing the bones out of their normal position.
The most commonly affected joints are those in the:
Find out more about osteoarthritis
In the UK, rheumatoid arthritis affects more than 400,000 people.
It often starts when a person is between 40 and 50 years old. Women are 3 times more likely to be affected than men.
In rheumatoid arthritis, the body’s immune system targets affected joints, which leads to pain and swelling.
The outer covering (synovium) of the joint is the first place affected.
This can then spread across the joint, leading to further swelling and a change in the joint’s shape. This may cause the bone and cartilage to break down.
People with rheumatoid arthritis can also develop problems with other tissues and organs in their body.
Find out more about rheumatoid arthritis
- ankylosing spondylitis – a long-term inflammatory condition that mainly affects the bones, muscles and ligaments of the spine, leading to stiffness and joints fusing together. Other problems can include the swelling of tendons, eyes and large joints.
- cervical spondylosis – also known as degenerative osteoarthritis, cervical spondylitis affects the joints and bones in the neck, which can lead to pain and stiffness.
- fibromyalgia – causes pain in the body’s muscles, ligaments and tendons.
- lupus – an autoimmune condition that can affect many different organs and the body’s tissues.
- gout – a type of arthritis caused by too much uric acid in the body. This can be left in joints (usually affecting the big toe), but can develop in any joint. It causes intense pain, redness and swelling.
- psoriatic arthritis – an inflammatory joint condition that can affect people with psoriasis.
- enteropathic arthritis – a form of chronic inflammatory arthritis associated with inflammatory bowel disease (IBD), the 2 main types being ulcerative colitis and Crohn’s disease. About 1 in 5 people with Crohn’s disease or ulcerative colitis will develop enteropathic arthritis. The most common areas affected by inflammation are the peripheral (limb) joints and the spine.
- reactive arthritis – this can cause inflammation of the joints, eyes and the tube that urine passes through (urethra). It develops shortly after an infection of the bowel, genital tract or, less frequently, after a throat infection.
- secondary arthritis – a type of arthritis that can develop after a joint injury and sometimes occurs many years afterwards.
- polymyalgia rheumatica – a condition that almost always affects people over 50 years of age, where the immune system causes muscle pain and stiffness, usually across the shoulders and tops of the legs. It can also cause joint inflammation.
Hip Surgery for Rheumatoid Arthritis
Characteristics of rheumatoid arthritis of the hip
As with any joint in the body the hip joint can be destroyed by rheumatoid arthritis. This can lead to pain stiffness and disability. Pain associated with destruction of the hip joint typically occurs in the groin upper outer thigh and/or buttock. In the early stages of the disease it is aggravated by weight bearing activity. Later it occurs at rest and can interfere with sleep.
Incidence and risk factors
Hip joint involvement by RA is less common and occurs later than other major joints such as the knees.
A thorough history will determine the patient’s overall health and functional capacity. Examination of the spine hips knees ankles and feet for joint range of motion and deformity is done. Radiographs (X-rays) of the involved joints are obtained. These usually include neck X-rays in which the patient is first asked to bend their head forward then backward. Occasionally an MRI scan CAT scan (CT) or Bone-scan may be necessary.
In early stages of RA anti-inflammatory medications can be effective in decreasing pain and may slow the progression of joint destruction caused by RA.
Once joint destruction of the hip has set in there are no specific exercises that can stop or arrest the development and progression of destruction. Regular range of motion exercises and weight bearing activity are important in maintaining muscle strength and overall aerobic (heart and lung) capacity and help prevent the development of osteoporosis which can complicate later treatment.
Possible benefits of hip surgery for rheumatoid arthritis
Total hip replacement very effectively eliminates the pain caused by RA of the hip.
Who should consider hip surgery for rheumatoid arthritis?
RA patients who have unrelenting hip pain and destructive arthritis of their hip joint that does not respond favorably to medical management should consider total hip replacement. RA patients with hip involvement in early stages who do not yet have destructive arthritis yet have unexplained debilitating pain should consider hip arthroscopy.
What happens without surgery?
The best case scenario includes inactivity and decreased mobility in conjunction with antirheumatic medication and steroids can cause some improvement of symptoms.
A worst case scenario might be severe destruction of the hip joint and associated osteoporosis and reduced physical capacity potentially leading to a compromised hip replacement at a later stage with a less predictable outcome.
Total hip replacement is the treatment of choice for patient with rheumatoid arthritis with destroyed hip joints. Occasionally hip arthroscopy is indicated in patients with early RA of the hip.
Not all surgical cases are the same, this is only an example to be used for patient education.
Not all surgical cases are the same, this is only an example to be used for patient education.
More than 80% of patients will have a satisfactory result for 12-15 years after hip replacement surgery.
Hip replacement surgery is an elective procedure and should be done only after non-surgical medical management has failed. Once indicated postponing the surgery for an extended period of time (months or years) only leads to increased disability disuse osteoporosis and skeletal complications that can make surgery more difficult and potentially compromise the final result.
The most common risks of hip replacement surgery for RA are infection dislocation of the hip joint and mechanical failure due to loosening of metal components from the bone. Mechanical loosening occurs in approximately 13% over 12 years and is mostly due to loosening of the metal socket. Infections and dislocations occur in approximately 2% of patients. Infection and dislocation can cause early failure and might prohibit a good result.
These complications can necessitate a revision hip replacement. If an infection occurs then the prosthesis needs to be removed. A six week period of antibiotic treatment is needed and if the infection is cured a revision hip replacement can be done. If the hip dislocates it needs to be relocated in the emergency room with sedation or in the operating room under anesthetic. Recurrent dislocations can lead to revision hip replacement surgery.
Hip replacement in a patient with RA requires an experienced orthopedic surgeon with a strong total joint background and the resources of a large medical center. Patients with RA have complex medical needs and around surgery often require immediate access to a multiple medical and surgical specialties and in-house medical physical therapy and social support services.
Finding an experienced surgeon
- MEDCON (206) 543-5300
- American Academy of Orthopedic Surgeons: (800) 346-AAOS
- Washington State Medical Society: (206) 441-9762 (Will connect to local County Medical Society)
A large hospital usually with academic affiliation and equipped with state of the art radiologic imaging equipment and Intensive Medicine Care Unit is clearly preferable in the care of patients with hip RA.
The surgeon will expose the affected area of the hip through an incision over the bony prominence at the upper outer thigh. This allow for dislocation of the hip removal of the head of the femur and cleaning of the destroyed socket without damaging the major hip muscles. After being machined to a perfect hemisphere the socket is replaced by a metal cup fixed directly to bone. A special plastic liner is inserted into the cup. A metallic femoral component is then fitted directly to bone or alternatively cemented into the femur. A metal or ceramic ball is then fit onto the femoral component and the new hip joint is reduced and the surgical incision closed.
Typically an epidural anesthetic with a general anesthetic is used for this type of surgery.
Length of hip surgery for rheumatoid arthritis
Depending on the complexity of the case most surgeries last 2 hours.
Recovering from surgery
Pain and pain management
Analgesics administered through the epidural catheter placed for surgery are very effective for controlling postoperative pain and are used for approximately 48 hours. Patient controlled intravenous narcotics can be used as a substitute for or supplement to epidural analgesics. By the third postoperative day oral narcotics are usually sufficient for pain relief and are quickly tapered according to individual patient needs. After that oral narcotics are administered and provided for the first two to four weeks after the patient has been discharged.
These medications are very effective in relieving the pain associated with total hip replacement. Dryness in the mouth sleepiness lightheadedness and constipation are the most frequent side effects of narcotic medications. The most serious side effect is suppression of respiration.
The patients are cared for in the hospital by trained nurses and doctors. Mobilization begins immediately after surgery in the hospital bed. Surgical wound dressings are changed daily beginning on the second postoperative day.
Recovery and rehabilitation in the hospital
90% of recovery takes place within the first six weeks. Rehabilitation begins on the first postoperative day. It starts with sitting or standing at the bedside and progresses to walking with assistance and stair climbing. Precautions to prevent dislocation of the hip are taught. Instruction in the use of assistive devices is given.
The patient is discharged with oral narcotics to ensure comfort at home. Patients are usually ambulatory with a walker and independently mobilize from bed to walking. Physical activity and joint range of motion limitations are clearly provided by the physical therapist mainly to prevent dislocation of the hip. The hip can only be flexed up to 60 degrees the patient has to sleep with a pillow between the legs and is not allowed to cross the legs for the first six weeks after surgery.
Most patients go home after 4-5 days. In the hospital they do though need some help for basic care especially those people with multiple joint involvement. If they do not have help at home then a short stay at a rehabilitation/convalescent facility will be necessary until they can resume independent living.
Very little physical therapy is required after total hip arthroplasty. Therapists reinforce hip precautions supervise ambulation and provide muscle strengthening.
Physical therapy begins with the inpatient rehabilitation described above. After returning home physical therapy can continue with the therapist coming to the patients home or in the therapist’s office as needed. Most people do not require any physical therapy outside the home.
Only a small number of patients need therapy after 6 weeks–mostly to help them achieve a normal gait.
Returning to ordinary daily activities
At 6 weeks most of the hip dislocation precautions can be stopped. Patients can then can sit with hips flexed at 90 degrees sleep without a pillow between the legs and can walk without a walking aid. Most ordinary daily activities can be resumed.
Long-term patient limitations
We do not recommend high impact activities like down hill skiing running and jumping. The patient should always avoid putting shoes on with the hip in flexion and internal rotation and should avoid sitting on low stools. Lifetime prophylactic antibiotic therapy is recommended prior to dental procedures or any invasive diagnostic procedure (i.e. colonoscopy).
Rheumatoid Arthritis Hip Pain Treatments That Work
When it comes to treating hip pain from rheumatoid arthritis (RA), there are several challenges. For one thing, the hip joint is difficult to reach, because it’s usually buried well below the surface of the skin (compared with, say, the joints in the hands, wrists, or feet). “The hip can be involved in rheumatoid arthritis, but doctors can’t grab the joint with their hands,” says Veena K. Ranganath, MD, an associate clinical professor of medicine in the division of rheumatology at UCLA Health in Los Angeles. “Because it’s a deep joint, we can’t feel it for swelling; we may need imaging, such as X-rays or an MRI scan, to determine if it’s real hip pain.”
Determine the True Cause of Hip Pain to Inform Treatment Options
After all, hip pain can have other causes, even if you have RA. It could be due to trochanteric bursitis (inflammation of the bursa along the outer side of the thigh bone), gluteal tendinitis (inflammation of the tendons that attach the gluteal muscles to the thigh bone), or iliotibial band syndrome (an injury to the band of fibrous tissue that runs down the outside of the thigh), Dr. Ranganath notes.
Treating Bursitis and Iliotibial Band Syndrome in Hips vs. Tendinitis in Hips
If the hip pain is due to trochanteric bursitis or iliotibial band syndrome, for example, a 7-to-10-day course of nonsteroidal anti-inflammatory drugs (NSAIDs) might be prescribed, perhaps along with physical therapy and stretching exercises, Ranganath says. By contrast, gluteal tendinitis may require a corticosteroid injection to calm the inflammation.
Depending on Pain Location, Injectable or Oral Medications May Help
If the hip pain is due to RA and only the hips are affected, your doctor may recommend ultrasound-guided corticosteroid injections to reduce inflammation and pain, Ranganath says. “If other joints are painful, too, switching to a biologic agent can help optimize treatment.”
Stretches and Hot or Cold Therapies for Complementary Hip Pain Relief
Stretching the muscles and tendons that surround the hip joint also may help ease your hip pain. The same is true of applying hot or cold packs — “the choice depends on patient preference,” Ranganath says — for 5 to 10 minutes twice a day. (The heat will stimulate blood flow to the area, which can ease the pain, whereas the cold will reduce inflammation and slow the transmission of pain signals.)
Pain-Relieving Topical Creams Help Hip Pain, Too
Similarly, applying a topical pain-relieving cream with methyl salicylate and menthol (such as Bengay or Icy Hot) can help. “One of the reasons they may work is because the anti-inflammatory drug is absorbed through the skin into the bloodstream and it decreases systemic inflammation,” says Bernard R. Rubin, DO, the division head of rheumatology at the Henry Ford Hospital and a clinical professor of medicine at Wayne State University in Detroit.
Sit Less, Stand More to Improve Hip Pain and Other RA Symptoms
What’s more, reducing the amount of time you spend sitting can help ease your hip pain by reducing pressure on your hips and pelvis. A study in the September 2017 issue of the Annals of Rheumatic Diseases found that when participants with rheumatoid arthritis decreased their sitting time by 1.6 hours in favor of spending increased time standing and stepping, more than 60 percent of them experienced significant improvements in their pain and fatigue levels. Like hip-specific stretches, standing is an easy enough intervention to try, without a doctor’s Rx.
Osteoarthritis, also called degenerative arthritis, is a gradual breakdown of cartilage in the joints. Cartilage is a tough, flexible connective tissue that protects the ends of bones in the joints. Osteoarthritis is common in the hip because the hip bears the weight of the body. Osteoarthritis of the hip can severely impact a person’s lifestyle.
Arthritis is a condition that causes pain, stiffness and swelling in the joints, which can include the hips. Hip arthritis is most often found in older individuals, although it sometimes develops in younger adults and even children. Arthritis may occur due to a gradual wearing down of the cartilage that protects the bones of the joint, or from overuse or injury to the hip joint.
Over time, hip joints affected by arthritis may become severely damaged. Hip arthritis is typically characterized by pain, tenderness and swelling, and may result in loss of movement in the hip joints.
Types of Hip Arthritis
In most cases, arthritis of the hip is a result of osteoarthritis, a degenerative condition that causes cartilage to become progressively weaker due to the aging process. Hip arthritis may also be inflammatory, which occurs when the immune system becomes overactive and begins to attack healthy tissue. Inflammatory hip arthritis can occur in patients of any age.
Types of inflammatory hip arthritis include:
- Rheumatoid arthritis, an autoimmune disorder that causes pain and swelling in the lining of the hip joint.
- Ankylosing spondylitis, a form of inflammatory arthritis that leads to swelling between the vertebrae. This often affects the sacroiliac joints and eventually spreads to the hips.
- Systemic lupus erythematosus, a condition that causes inflammation and weakened bone structure in the hips. It is most often found in young adult women.
Causes of Hip Arthritis
There are a variety of factors that may contribute to the development of hip arthritis. The condition generally occurs in older adults, though it can develop in younger patients including children, especially if the hip joint is injured or overused. Hip arthritis is also linked to genetics, and is more prevalent in those with certain health conditions, such as obesity.
Symptoms of Hip Arthritis
Patients with hip arthritis usually experience difficulty walking, since the pain can manifest itself in not only the hip, but also the groin, thigh, buttocks or knee. Additionally, patients may have quite a bit of discomfort after they have been seated for a long period of time. The pain is often described as sharp and intense. Symptoms of hip arthritis may include:
- Stiffness in the hip
- Pain, swelling or tenderness at the hip joint
- A crunching type of sound in the hip upon certain movements
- Inability to move the hip to perform routine activities, such as putting on socks
Diagnosis of Hip Arthritis
Hip arthritis is diagnosed after an evaluation of the patient’s medical history and symptoms and a physical examination. The physical examination will focus on assessing the overall range of motion within the hip. Additional diagnostic tests may include:
- Joint fluid testing
- Blood tests
- MRI scans
Treatment for Hip Arthritis
There are several effective treatment options designed to help prevent further deterioration of the hip joint. Conservative measures may include non-steroidal anti-inflammatory drugs, physical therapy and assistive devices, such as using a cane for added support while walking. Heat and cold therapy may also relieve pain and swelling in the hips. For more severe cases of hip arthritis in which the symptoms are not alleviated by these treatments, surgery may be required to repair tendons or replace damaged joints.
There are several surgical options for treating hip arthritis, including hip arthroscopy, a minimally invasive procedure performed using a flexible tube with an attached camera known as an arthroscope. The arthroscope helps the surgeon thoroughly view the affected joint to remove any loose bodies and damaged cartilage, or realign the joint to minimize pain and inflammation. In other cases, the best treatment option may be total hip replacement surgery. This procedure, commonly recommended for patients with rheumatoid arthritis, involves the removal of cartilage and bone. They are replaced with metal or plastic joint replacements to restore the function of the hip.
Prevention of Hip Arthritis
Early diagnosis of hip arthritis may prevent the condition from progressing, and help patients maintain mobility and function. In addition to medical treatment, some forms of arthritis may respond to lifestyle changes such as losing weight, eating a healthy diet and exercise.
How Rheumatoid Arthritis Affects the Hips
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Rheumatoid arthritis (RA) usually affects hands, feet, and knee joints on both sides of your body. But RA can affect any joint, including the hip joint. About 15 to 28% of people with RA develop hip RA. Most people with hip RA experience it later on as their RA progresses.
Symptoms of Hip RA
If you have hip RA, you may have symptoms in one or both hips. It may be the only joint affected by your RA. As with your other joints, you will probably notice morning pain and stiffness. Over time, you may also develop:
Dull aching pain
Pain that spreads to your groin, thigh, or buttock
Pain that gets worse with walking or standing
Walking with a limp
Pain even when resting
Diagnosing Hip RA
Your doctor may suspect hip involvement if you start to have hip pain and stiffness later on in the course of your RA. Your doctor may ask questions about your pain and move your hip in different directions during a physical exam to find out how much pain and stiffness you have.
The most important part of your diagnosis is X-rays. Your doctor will look for these signs on an X-ray of your hips:
Thinning of hip bones and bone erosion
Loss of joint space
Fluid inside the joint
Treating Hip RA
In the early stages of hip RA, your treatment may include these RA medications:
Drugs that fight symptoms of inflammation, called symptom-modifying anti-rheumatic drugs, or SMARDs
Drugs that block inflammation, called disease-modifying anti-rheumatic drugs, or DMARDs
A new type of DMARD called biologics, which may be used if SMARDs and DMARDs are not helping
Biologic drugs change parts of your body’s defense system, called the immune system, to block inflammation. If hip RA progresses, other treatments may include:
Physical therapy to increase range of motion and muscle strength
A cane, walker, or other assistive device
Hip Replacement Surgery for Hip RA
For severe hip RA, a total hip joint replacement may be the best treatment. This surgery provides pain relief and restores motion. If RA has started to destroy your hip joint, physical therapy will not be able to prevent further pain and disability.
Total hip replacement is recommended for people with continuing pain and signs of joint destruction on X-rays. More than 80% of people who have joint replacement surgery have good results that will last for up to 15 years.
RA of the hip joint is less common, but it may occur as a later symptom in up to 28% of people with RA.
Symptoms often include increasing pain and stiffness that spread to the thigh, groin, and buttocks.
X-rays of the hip joint may show bone changes, loss of joint space, fluid in the joint, and gradual destruction of the joint.
If pain and disability continue to worsen despite treatment, total hip replacement may be the best option.
Total hip replacement relieves pain and restores motion about 80% of the time.
2. Case Presentation
A 57-year-old Caucasian woman was referred to our rheumatology outpatient center from the orthopedics service for assessment of a possible inflammatory etiology for her rapidly destructive arthritis. Table 1 summarizes the major clinical, lab, and imaging findings. She initially presented with 6 months of progressive right hip and groin pain with no preceding trauma or chronic steroid use. There was a leg length discrepancy with the right leg 3 cm shorter and severe limitation of the right hip and some decreased range of motion on internal and external rotation of her left hip. She did not have any neurovascular compromise. Over 5 months, she became severely disabled and was unable to ambulate. With respect to her other joints, she had chronic pain in her metatarsal phalangeal joints (MTPs) and toes for approximately 3 years with progressive deformities, with recent episodes of swelling. Subsequent to her right hip pain, she also developed right knee pain with multiple episodes of warmth and swelling. Morning stiffness in affected joints was approximately 2 hours. Her initial swollen joint count (SJC) was 8 out of 66 joints examined, involving her right knee and multiple metatarsal phalangeal joints (MTPs). Over the next few visits, her swollen joint count of her small joints reached 11. There was also an unintentional 50-pound (lb) weight loss since the onset of her illness, partially due to decreased appetite secondary to pain.
Major clinical, lab, and imaging findings.
|(1) Rapid progressive right hip destructive arthritis|
|(2) Morning stiffness greater than 1 hour|
|(3) Maximum active joint count of 11|
|(4) Chronic metatarsal phalangeal joints arthritis with erosions, periarticular osteopenia on imaging of hands|
|(5) Right knee arthritis with no imaging evidence of crystal arthropathy|
|(6) Erythrocyte sedimentation rate (ESR) of 56 mm/h and C-reactive protein (CRP) 106.4 mg/L, antinuclear antibody (ANA) was weakly positive at 1:80, with a negative rheumatoid factor (RF), anticitrullinated peptide (anti-CCP), antidouble stranded DNA (anti-dsDNA), and extractable nuclear antigen (ENA) screen|
|(7) Two incidental pulmonary nodules|
|(8) A soft tissue calcified mass in the right sacroiliac (SI) fossa and right gluteal muscles|
|(9) Presence of extracellular calcium pyrophosphate dehydrate (CPPD) crystals in right hip joint, negative synovial biopsy for crystals|
|(10) Biopsy showed chronic inflammation, fibrosis, multinucleated giant cell reaction with dystrophic calcification, and reactive synovial proliferation|
Initial diagnostic work-up was significant for elevated inflammatory markers, weakly positive antinuclear antibody (ANA) and otherwise negative autoimmune markers including both rheumatoid factor (RF) and anticitrullinated peptide (anti-CCP) (Table 1). All cultures, including three sets of anaerobic and aerobic cultures and one set of systemic fungal and mycobacterial culture, were negative. Metabolic panel showed normal renal, thyroid, and liver function. Angiotensin-converting enzyme (ACE) serum level was within normal limits. Malignancy work-up was negative: serum and urine electrophoresis, CEA, CA-125, total body position-emission tomography (PET) scan, and bone scan were all within normal range. Two incidental pulmonary nodules were found on computed tomography (CT) thorax with focal ground glass appearance, but negative for malignancy on bronchoscopy and on repeat imaging. CT abdomen and pelvis was negative for any abdominal masses and showed a soft tissue calcified mass in the right sacroiliac (SI) fossa and right gluteal muscles.
Initial plain films of her right hip and pelvis showed femoral head lucencies compatible with subchondral cysts (but no definite fracture) and moderate diffuse articular joint space loss with flattening of the femoral head (Figure 1(a)). Over a 5-month span, there was complete destruction of the right femoral head, erosion of the right acetabulum, and lateral subluxation of the proximal femur (Figure 1(b)). CT pelvis with contrast (Figure 1(c)) showed fragmented bone within the acetabular fossa, which was remnants of the femoral head resorption process. Magnetic resonance imaging (MRI) of the right hip showed extensive synovial hypertrophy consistent with inflammatory arthritis (Figure 2). There were also minimal bone marrow edema and a fluid collection in the iliopsoas bursa extending posteriorly to the sciatic notch and enlargement of the hip joint capsule (Figure 2). X-rays of her feet revealed erosive changes in the MTPs and X-rays of her hands showed periarticular osteopenia in her metacarpal phalangeal (MCP) joints and ulnar deviation. There were degenerative changes on imaging of her knees, shoulders, and spine.
(a) AP radiograph of the right hip. A focal area of subchondral lucency is present involving the superolateral aspect of the right femoral head (arrow). (b) The follow-up radiograph taken 5 months later reveals near complete destruction of the femoral head. (c) CT scan of the right hip in the axial plane shows loss of the femoral head with two bone fragments within the hip joint (arrows).
(a) Axial proton density with fat saturation sequence through the right hip joint (a) shows destruction of the femoral head (arrow) and a complex joint effusion (arrowhead). (b) Axial T1 fat saturated sequence after gadolinium reveals synovial thickening and enhancement (arrow).
Three right hip aspirations were attempted with sufficient sample in only one attempt, which showed bloody fluid, 0.6 nucleated cells (17% neutrophils), and presence of only extracellular but not intracellular calcium pyrophosphate dehydrate (CPPD) crystals. Synovial biopsy did not reveal any crystals. Historically, CPPD crystal deposition disease can cause such acutely destructive disease on imaging and pathology , but the most common sites of CPPD joint involvement are the knees, wrists, and symphysis pubis with hip involvement being rarer with a prevalence of 5% . This patient’s plain-film images of her hands, knees, and pelvis were helpful in that there were no typical features of crystal arthropathy such as cartilage or joint capsule calcification and her blood work was also negative for an underlying metabolic precipitant of CPPD. Furthermore, single joint aspiration of her right knee showed no crystals, with bloody fluid and 35 nucleated cells (96% neutrophils).
The major differential diagnosis of this atypical case of destructive arthritis is outlined in Table 2. The patient’s initial plain films showed evidence of degenerative changes but very unlikely to be primary osteoarthritis given the atypical symmetric joint space narrowing on plain imaging, complex joint effusion, and synovial thickening with chronic inflammatory changes on biopsy. She also did not have any evidence of a subchondral insufficiency fracture, which has been linked to the pathogenesis of the rapid destruction of osteoarthritic joints . Other potential etiologies that could rarely cause such severe arthritis were considered on the differential including systemic diseases such as multicentric histiocytosis and sarcoidosis, but the patient lacked any other features of these diseases. Her neurovascular status was intact throughout and no evidence of a neurological problem or predisposing factors such as diabetes to cause Charcot’s or neuropathic arthropathy. An avascular type necrosis (AVN) with subsequent inflammation was possible, but unusual without a history of steroidal use prior to her initial presentation or other risk factors for AVN. The imaging was also not classic for AVN and the patient did not have monoarthritis. Although seronegative, she did not have any inflammatory back pain, dactylitis, enthesitis, DIP involvement, inflammatory bowel disease, psoriasis, or other features of seronegative spondyloarthropathy. X-rays of her spine and CT pelvis did not show evidence of sacroiliitis.
Major differential diagnosis of rapidly destructive coxarthrosis.
|(1) Infectious particularly mycobacterial and fungal|
|(2) Crystal arthropathy|
|(3) Avascular necrosis|
|(4) Inflammatory such as rheumatoid arthritis|
|(7) Seronegative spondyloarthropathy|
|(8) Multicentric histiocytosis|
In order to definitively differentiate between chronic sepsis, malignancy, and a chronic inflammatory process, an open biopsy of the hip was performed by the orthopaedic service, which showed overall morphology with features of chronic inflammation, fibrosis, multinucleated giant cell reaction with dystrophic calcification, and reactive synovial proliferation (Figure 3). Cultures of synovial tissue were negative for fungus and mycobacteria, ruling out tuberculosis. Although the biopsy results were not specific for an exact etiology of rapid joint destruction, we were able to exclude neoplastic, infectious, osteoarthritis, and osteonecrotic etiologies.
(a) Papillary, hyperplastic, chronically inflamed synovium is shown with abundant fibrin covering the surface and multiple fragments of bone being degraded by histiocytes and multinucleated giant cells. (b) At higher magnification, fibrin is seen on the surface of the synovium with a hyperplastic synovium consistent with chronic inflammation. (c) Fibrin and bone are detailed at 40x magnification showing multiple bone fragments which is typical of a rapidly destructive joint process. (d) Bone is seen being further broken down by multinucleated giant cells.
An inflammatory etiology was most likely given multiple swollen joints, elevated inflammatory markers, constitutional symptoms, evidence of inflammatory features on imaging, and other causes excluded. Hence, a diagnosis of seronegative rheumatoid arthritis (RA) was ultimately made, fulfilling 4/7 of the 1987 RA American College of Rheumatology (ACR) classification criteria and scoring 6 points for the 2010 ACR//European League Against Rheumatism (EULAR) classification criteria (Table 3). Given the extent of right hip destruction, the patient received a total hip arthroplasty with good results. To prevent destruction of her other joints, triple disease modifying antirheumatic drugs (DMARD) therapy with hydroxychloroquine 400 mg daily, leflunomide 20 mg daily, and methotrexate 25 subcutaneously weekly was initiated. For symptom relief, she was given an 80 mg intramuscular Depo-Medrol injection and joint injection to her right knee. At her 2-month follow-up visit, she had significantly reduced swelling of her knees and MTP’s with much symptomatic relief. Adalimumab was added because of incomplete response and patient had further improvement. Over a 6-month period, SJC decreased from 8 to 1/66.
Rheumatoid arthritis classification criteria.
(a) 1987 American College of Rheumatology (ACR)
(b) 2010 ACR/European League of Rheumatism (EULAR)
|Greater than 10 small joints (4)|
|Abnormal CRP and ESR (1)|
|Symptoms > 6 weeks (1)|
|Total: 6 points|
Table 3 details the clinical classification criteria of rheumatoid arthritis (RA) that the patient fulfills as part of the 1987 American College of Rheumatology criteria (A) and 2010 American College of Rheumatology/European League of Rheumatism criteria (B). Only the features the patient had that met criteria are shown with the number of points in brackets.