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Journal of the American Academy of Orthopaedic Surgeons320

Osteoarthritis (OA) of the hip ismanifested as degeneration of thetissues of the hip joint, includinghyaline cartilage, fibrocartilage,

bone, and synovium. Hip arthritiscan result from several differentpatterns of joint failure. Underlyingpathologic changes due to condi-tions such as osteonecrosis, trauma,sepsis, Pagets disease, and rheuma-toid arthritis can produce degenera-tion of the joint. Conditions such asdevelopmental dysplasia of the hip(DDH) and slipped capital femoralepiphysis (SCFE) leave the patientwith predisposing anatomic abnor-

malities that can later result in os-teoarthritic changes. When any ofthese conditions can be identified(Table 1), the degenerative process

is termed secondary OA. Whenneither an anatomic abnormalitynor any specific disease process canbe identified, the condition is calledprimary OA, which is, therefore, adiagnosis made by exclusion.

Clinical and epidemiologic stud-ies indicate that OA of the hip is adistinct entity that behaves different-ly from OA in other synovial joints.1

Patients who have undergone totalhip replacement (THR) because of a

Dr. Hoaglund is Professor (Emeritus) of Ortho-paedic Surgery, University of California at SanFrancisco Medical Center, San Francisco. Dr.Steinbach is Professor of Radiology and Ortho-

paedic Surgery, University of California at SanFrancisco Medical Center.

Reprint requests: Dr. Hoaglund, Departmentof Orthopaedic Surgery, UCSF Medical Center,500 Parnassus Avenue (MU 320-W), SanFrancisco, CA 94143-0728.

Copyright 2001 by the American Academy ofOrthopaedic Surgeons.

Abstract

Primary osteoarthritis (OA) of the hip has a distinct etiology and epidemiologycompared with other types of arthropathy in the hip joint. Arthritis of the hip canbe secondary to conditions such as osteonecrosis, trauma, sepsis, or rheumatoidarthritis. Certain conditions, such as congenital hip disease and slipped capital

femoral epiphysis, involve predisposing anatomic abnormalities; in such cases, the

term secondary OA is used. When either an anatomic abnormality cannot bedetermined or other specific causative entities are not identified, primary OA isthe diagnosis of exclusion. The prevalence of hip OA is about 3% to 6% in theCaucasian population and has not changed in the past four decades. In contrast,studies in Asian, black, and East Indian populations indicate a very low preva-lence of hip OA. Statistics on patients who underwent total hip replacement for

primary OA in San Francisco and Hawaii demonstrate a virtual absence of thecondition in Asians and low rates in the black and Hispanic populations. Familystudies from Sweden, Britain, and the United States show increased rates of hipOA in first-degree relatives of the index patient when compared with the normal

population. Occupations requiring heavy lifting, farming, and elite sports activi-ty are associated with increased rates of hip OA. The low prevalence of hip OA in

Asian and black populations in their native countries; the low incidence of totaljoint replacement for primary OA in Asian, black, and Hispanic populations inNorth America; and the familial association of hip OA in Caucasians all suggestthat genetic factors may be involved in the occurrence of this disease.

J Am Acad Orthop Surg 2001;9:320-327

Primary Osteoarthritis of the Hip:

Etiology and Epidemiology

Franklin T. Hoaglund, MD, and Lynne S. Steinbach, MD

diagnosis of primary OA rarelyundergo total knee replacement, andvice versa.2 In two other studies,Japanese and Hong Kong Chinesepopulations had virtually no pri-

mary OA of the hip but a consider-able incidence of knee OA.3,4

Epidemiology

The modern search for the causes ofOA started with the work of Britishscientists Kellgren and Lawrence,who carried out epidemiologic stud-ies encompassing several ethnicgroups in a number of geographic

areas, including western Europeanand specifically British Caucasians,African and Jamaican blacks, andNative Americans.5-7 Responses toquestionnaires and the clinicalfindings in randomly selected pop-ulations were evaluated, and radio-graphs of various joints were ex-


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Vol 9, No 5, September/October 2001 321

amined with the use of standard-ized grading.5-7 Patients were con-sidered to have generalized OA ifthree or more joint groups wereinvolved. Evaluation of these datawas the basis for an atlas that isstill used today to characterize the

various degrees of OA.5These researchers found that the

incidence of OA was not related tolatitude or longitude. The highestprevalence of OA occurred in theCaucasians. It was noted that OA pref-erentially affected the distal inter-phalangeal joints and the first carpo-metacarpal joints of the hands, theknees, and the first metatarsopha-langeal joints. Comparisons betweenethnic groups were not particularly

helpful in delineating the etiology ofOA; however, the marked ethnic andracial differences in the incidenceof hip OA were important observa-tions.6

Population Studies

Lawrence and Sebo6 studied thecomparative incidence of radio-graphic OA of the hip by evaluatingpelvic radiographs of EuropeanCaucasians, blacks, and Native

Americans from nine geographicareas. The term radiographic OAwas used because there was nointent to distinguish primary or sec-ondary OA from other specific causesof hip disease. Kellgrens gradingsystem was used to characterize the

degree of hip arthritis as absent(grade 0), doubtful (grade 1), mini-mal (grade 2), moderate (grade 3),or severe (grade 4). The incidencesof grade 2-4 and grade 3-4 OA werehigher in the Caucasian males thanin the females (Table 2). The rate ofmoderate and severe OA in Cau-casians was three to four times thatin blacks and Native Americans.

Hoaglund et al4 also evaluatedconventional radiographs of the

hands, knees, and hips of 500 HongKong Chinese subjects. An ex-tremely low rate of OA of the hip(1%) was found, but the incidenceof hand OA was similar to that inEuropean Caucasians. A secondstudy was done 20 years after theoriginal study. Pelvic radiographsof 999 Hong Kong Chinese men ob-tained during intravenous pyelog-raphy demonstrated no change inthe incidence of hip OA.8

In another study, a group of51,777 East Indians who visited anorthopaedic clinic in India wereexamined.9 The incidence of OAwas found to be less than 0.1%.

Pelvic radiographs of American

Caucasians demonstrated that theprevalence of hip OA in patientsover 54 years of age was 2.7% to3.5%,10 which is lower than the rateseen in European Caucasians.6-11

In a Swedish study,12 pelvic radio-graphs obtained during double-contrast colon examinations wereevaluated. The overall incidence ofhip OA was 3.4% in 1964. There hasbeen no change in this rate over thepast four decades, as demonstrated

in follow-up studies performed in1984 and 1993.13

In summary, population studiesshow that the rate of moderate tosevere primary or secondary OA ofthe hip in Caucasians is 3% to6%, compared with 1% or less inEast Indians,9 blacks, Hong KongChinese, and Native Americans.The prevalence has not changed infour decades, suggesting that geneticand/or environmental factors remain

constant.

Hip Disease in Hip Surgery

Patients

Specific causes of hip diseaseand OA in patients who underwenthip surgery in the 1940s and 1950shave been evaluated.14-16 The rela-tive incidence of various hip dis-eases described in these series isquite different from the currentincidence. During that era, 20% to

50% of surgical cases were due toLegg-Calv-Perthes disease, DDH,or SCFE. One might have expecteda higher incidence of adults pre-senting with a painful hip due toarthritic changes from these causes,because there was no prophylactictreatment for these conditions orgood early surgical reconstructionat that time.

There has been an ongoing de-bate about whether the high rate of

Table 1Causes of Secondary OA and Their Radiographic Appearance

Condition Radiographic Features*

Osteonecrosis Sclerosis, lucency, flattening of femoral head

Pagets disease Osseous enlargement, trabecular coarsening,cortical thickening

Inflammatory arthropathy Joint-space narrowing, osteopenia, erosion

Traumatic remodeling Distortion of osseous contour with sclerosisand remodeling

Degenerative dysplasia Shallow acetabulum with increased acetabularof the hip index, subluxation, or dislocation

Slipped capital femoral Medial and/or posterior displacement ofepiphysis femoral head, convexity at head-neck

junction, short femoral head, coxa vara, shortbroad femoral neck

* In addition to joint-space narrowing and osteophytes.


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Primary Osteoarthritis of the Hip


secondary OA in that period con-tinues today. Studies of THR pa-tients in Europe and the UnitedStates have provided informationabout the frequency of all causes ofhip arthritis in various populations.The prevalence data were compa-rable among Caucasian populationgroups in the United States, Scan-dinavia, and western Europe. Therate of THR varied from approxi-mately 60 per 100,000 persons in

the Mayo Clinic data to 140 per100,000 in Norway17 (Table 3).When other specific causes of hipdisease were excluded, it was notedthat primary OA was the underlyingdisorder in nearly 90% of osteoar-thritic hips. Similar published statis-tics for Africa, South America, HongKong, or Japan are not available.

The rate of THR for all residentsof San Francisco has been mea-sured for the years 1984 through

1988 using data from the 17 hospi-tals in or near the city (Table 4).22

Preoperative pelvic radiographswere evaluated for arthritis with-out the examiners knowledge ofthe gender or race of the patient.

Total hip replacement statistics forCaucasians were compared withthose for the sizable non-Caucasianpopulations (i.e., Asian, Hispanic,and black). Caucasians had a rateof THR of 75 per 100,000 persons,blacks had half the incidence, andAsians had only one tenth. Therewere markedly lower rates of THRperformed because of primary OAin non-Caucasians; for example,the rate was 1.3 per 100,000 for the

Chinese population, comparedwith 43 per 100,000 for Caucasians.The rates of THR for the othercauses of hip disease, includingsecondary OA, were not signifi-cantly different among the variousethnic groups.

This study was repeated in Ha-waii,23 with its large Asian andPacific Islander population (750,000persons). In the total Hawaiianpopulation, medical insurance is

available to more than 90% of thepatients, thus minimizing the effectof access to care as a factor. The re-sults of this study confirmed themarkedly higher rates of THR inCaucasians, who predominantlyhad primary OA (Table 4). The rateof THR for secondary OA in theCaucasian population was not sig-nificantly different from the ratesfor the Chinese, Filipino, Hawaiian,and Japanese populations.

Incidence of Predisposing

Anatomic Abnormalities

In 1965, Murray24 suggested thatsecondary OA was more commonthan primary OA. In that study, ra-diographs were evaluated looking

for evidence of DDH or femoralhead tilt. Previous DDH was foundin 37% of British women with OA,and a femoral-head tilt deformitywas noted in 74% of British menwith OA (Table 5). His conclusionthat OA was in fact secondary 90%of the time has been supported bysubsequent analysis of the data inuncontrolled series of hip surgerypatients in the United States25,26 andSouth Africa.27 However, there is

now considerable information frommore recent surgical series thatargues against such a high inci-dence of either DDH or SCFE as thecause of OA.

Measurements of the center-edge(CE) angle in blacks (who are rela-tively unaffected by DDH and hipOA) are the same as those in Cau-casians.28 (The CE angle is a mea-sure of hip socket coverage. A lowangle indicates a shallow socket,

which can predispose to secondaryOA). In one study, acetabular depthmeasurements and CE angles inBritish patients were the same innormal and osteoarthritic hips.29

The incidence of DDH based on CEangle measurements in Hong KongChinese men was not different fromthat in British men,8 yet osteoar-thritic hips are much less frequentin the Chinese. Although Japanesepersons have significantly smaller

Table 2Incidence of Hip OA in Maleand Female Subjects inPopulation Studies6

Incidence(M/F), %

Grades GradesSubjects (No.) 2-4 3-4

Caucasian (1,451) 20/12 6.5/5.75

Black (503) 2.3/3 1/1.6

NativeAmerican (545) 9/8.0 2.7/1.6

Table 3Relation Between THR and Primary OA in Various Nations17-21

Sweden Norway Denmark Finland USA United Kingdom France Belgium

Rate of THR per 100,000 persons 130 140 82 58 60 54 108 116

Incidence of primary OA, % NA 68 86 56 63 NA NA NA

* NA = data not available


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CE angles than British persons, theyhave much less hip OA.30

Lane et al31 found no differencein the incidence of an abnormal CEangle between American Caucasianwomen with OA of the hip andthose without it (4% to 5% in eachgroup). In this population, DDHdid not account for more than a fewosteoarthritic hips.

If primary OA of the hip is due to

a subtle dysplasia, it should be seenfrequently in Japanese persons, withtheir extremely high rate of dysplasia;however, primary OA is rare in thatpopulation.3,32 The incidence of DDHin Caucasians is 0.5%. If OA devel-oped in all children with DDH, thiswould account for only one eighth ofthe cases of OA in the Caucasian pop-ulation. Hawaiian Japanese womenhave the same rate of THR for dys-plastic OA as Caucasian women, but

their rate of THR performed for pri-mary OA is only one tenth of that forCaucasian women.23

In summary, when controlledstudies of acetabular measurementsare done and the rates of DDH andOA for each racial subgroup areconsidered, DDH accounts for only asmall percentage (5% to 10%) of hipOA in Caucasians.

Since the original publications ofHarris,26 Murray,24 Stulberg and

Harris,25 and Solomon,27 which sug-gested that OA was often caused bySCFE (Table 5), there has been newinformation that SCFE or subclinicalSCFE does not account for the highrate of primary OA. The tilt defor-mity seen in the adult with OA hasbeen shown to be due to a remod-eling process that causes progres-sion of osteophytes, rather than toan old epiphyseal slip.33 Goodman

et al34 identified a subtle or subclini-cal slip deformity in 8% of cadaverbone specimens from a large collec-tion of disarticulated femora andpelves. There are some similaritiesof this subclinical SCFE to SCFE,such as a lower incidence in women,

increased left-side prevalence, andincreased incidence in specimensfrom black subjects. However, clini-cal SCFE in the adolescent occurs inonly 1 of every 800 boys (an inci-dence of only 0.125%). Whethersubclinical SCFE is a forme fruste ofSCFE remains to be proved. Even ifit is, anatomically normal femoraaccounted for more than 80% of theOA in their series. Furthermore,

although there is little primary OAin the black and Polynesian popula-tions, as well as a low incidence ofTHR performed because of OA,22,23

these populations have two to fourtimes the rate of SCFE in Cauca-sians.

Table 4Rates of THR for Secondary and Primary OA by Ethnic/Racial Background in Two Studies22,23*

Chinese Japanese Filipino Caucasian Hispanic Black Hawaiian

San Francisco study22

Women 1.8/1.4 2.9/2.9 0.9/3.1 6.7/52.6 0/6.2 1.1/19.2 Men 0.4/1.1 0/0 0/0 1.8/33.9 0.8/6.3 0/10.1

Hawaii study23

Women 0.31/0.84 0.17/0.24 0.06/0.25 0.29/2.35 0/0.30Men 0/0.52 0.06/0.08 0/0.25 0.11/2.32 0.06/0.16

* Adapted with permission from Hoaglund FT, Oishi CS, Gialamas GG: Extreme variations in racial rates of total hip arthroplasty forprimary coxarthrosis: A population-based study in San Francisco. Ann Rheum Dis 1995;54:107-110. Also adapted with permissionfrom Oishi CS, Hoaglund FT, Gordon L, Ross PD: Total hip replacement rates are higher among Caucasians than Asians in Hawaii.Clin Orthop 1998;353:166-174.

Values are expressed as rates for secondary OA/primary OA per 100,000 population/yr.

Table 5Incidence of OA Due to DDH and Femoral-Head Tilt in Men and Womenin Four Studies24-27

StulbergMurray24 Solomon27 Harris26 and Harris25

Women

DDH 37% 69% 68% 65%

Tilt 11% 4.8% 10%

Men

DDH 11% 8% 15% 25%

Tilt 74% 45% 66%


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Etiology

Body Weight

Bioengineering studies haveshown that forces across the hipjoint are multiplied by a leverage

system involving muscles pullingagainst the weight of the body. Forexample, an individual standing onone foot has a force across the hipjoint of three to four times his orher body weight. Therefore, obesi-ty could be contributory in the eti-ology of primary OA of the hip.

Although OA of the knee hasbeen shown to be consistently relatedto obesity, there have been conflict-ing results regarding the relation-

ship of body weight to the develop-ment of OA of the hip. Saville andDickson35 found no difference in theaverage body weight of patientswith primary or secondary OA ofthe hip compared with control sub-jects. Spector36 and Tepper andHochberg37 found no relationshipbetween body weight or body-massindex and the occurrence of hip OA.However, other studies have shownan increased risk of OA of the hip

in obese individuals.38,39 The con-flicting findings concerning bodyweight and hip OA may be relatedin part to the fact that patients gainweight as a result of the immobilityimposed by a painful hip.

Occupational Factors

The physical demands of workhave been estimated to account for40% of cases of hip OA,40 and carry-ing heavy loads has been associated

with an increased rate of hip OA.Axmacher and Lindberg41 foundthat farmers were at increased riskfor hip OA in studies conducted inEngland, Sweden, and Franceallcountries that are known to havehigh rates of hip OA. However, theresearchers pointed out that farmersare usually members of families thathave been involved in farming formany generations; therefore, heredi-tary factors cannot be ruled out.

Studies conducted in Sweden in-dicated an increased risk of OA inpatients who had been involved intrack, field, and racket sports as wellas among soccer players (especiallythose who played professionally).42

The findings from these studiessupport the hypothesis that sportsmay exacerbate hereditary predis-position to OA of the hip.

Other Anatomic Considerations

There is a known association be-tween arthritis and previous DDHin patients with the mechanical fac-tors that predispose to secondaryOA, such as an acetabular abnor-mality or femoral anteversion.

Therefore, investigations have alsobeen done to determine the role offemoral anteversion alone in pa-tients with primary OA of the hip.However, small studies involvingcadaver specimens and patientswith hip arthropathy have shownvariable results.43-46 In cadaverspecimens without OA, there wasno correlation between femoralanteversion and acetabular angles.A study of Hong Kong Chinese

cadaver bones showed a high inci-dence of femoral anteversion com-pared with specimens obtainedfrom Caucasian subjects.47 Inas-much as hip OA is rare in the HongKong Chinese population, this ob-servation is inconsistent with ante-version being a factor in primaryOA of the hip.

Femoral anteversion in osteo-arthritic and normal subjects hasbee n me asur ed wi th the use of

biplanar and/or conventional (APand cross-table lateral) radio-graphs; a mild increase in antever-sion was found in some series butnot in others.43 This increase infemoral anteversion could be dueto measurement error. Using ac-curate CT techniques, Reikers etal46 found no difference in femoralanteversion between control sub-jects and a series of Caucasian pa-tients with OA.

Family Studies

In 1984, Lindberg48 studied 289siblings of 184 Swedish patients whohad undergone THR for primarycoxarthrosis. Coxarthrosis occurredin 8% of siblings. This represents a

statistically significant (P


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recent twin studies of OA of the hip,women showed a 50% heritability(95% CI, 20% to 74%).52

In summary, two different factorsappear to be involved in the etiologyof OA. First, the lower rates of pri-

mary OA in population studies ofnon-Caucasians and the differencein rates of THR for primary OA inpatients with various racial back-grounds living in a common envi-ronment suggest that it is a diseaseprimarily of Caucasians. Second,the relatively high incidence of thedisease in siblings of Swedish andEnglish patients who underwentTHR because of primary OA sug-gests that genetic factors are opera-

tional as well.

Radiographic Criteria

In the studies performed byHoaglund and co-workers in SanFrancisco22 and Hawaii,23 the radio-graphs were read without knowl-edge of the race of the patient. Therate of secondary OA in the Cau-casian population was not signifi-cantly different from the rates forChinese, Filipino, Hawaiian, and

Japanese subjects.The use of radiographic criteria

has been criticized as being generallyinadequate to establish that a caseclassified as primary OA is actuallysecondary OA. For example, DDHis thought to be underrepresentedin women with primary OA, andSCFE or a variation of it is thoughtto be underrepresented in men.However, evaluation of the radio-graphs of equivalent large Japanese

and Caucasian populations havedemonstrated that these criteria canbe used to distinguish between pri-mary and secondary OA.

The cumulative rates of THR forsecondary OA (measured in casesper 100,000 person-years) are similarfor Japanese women (0.17) andCaucasian women (0.29), but therate for primary OA in Japanesewomen was only one tenth (0.24) ofthat for the Caucasian women (2.35).

If large numbers of cases of primaryOA are in fact secondary OA, thereshould be sizable numbers in theJapanese women as well as in theCaucasian women.

The statistics for men show the

same disparity. The rate of sec-ondary OA in Japanese men is 0.6, incontrast to the rate of 0.11 for Cau-casian men. If no variant of SCFEwere distinguished on the basis ofradiographic criteria, comparablenumbers of primary OA would beseen in both Caucasian and Japanesemen. However, the rate of THR forCaucasians with primary OA is 29times that for the Japanese men, butthe rate of SCFE in Japanese men is

only one half to one fifth of that inCaucasians.

It seems clear, therefore, that useof radiographic criteria did not leadto underrepresentation of DDH inthe female subjects. Similarly, use ofthose criteria did not lead to under-representation of SCFE or subclinicalSCFE in male subjects.

Summary

Contributions to our understandingof the etiology of OA of the hiphave come from international popu-lation studies, joint replacement reg-istries, epidemiologic investigations,and, more recently, analysis of fam-ily pedigrees to investigate geneticfactors in this disease. Attempts toelucidate the etiology of OA of thehip depend on our ability to recog-nize and separate this condition

from other causes of hip disease, aswell as our ability to distinguishsecondary OA from primary OA.

Secondary OA of the hip occurswhen a condition such as DDH,SCFE, or Legg-Calv-Perthes diseaseresults in a predisposing anatomicabnormality that leads to hip degen-eration due to mechanical factors. Aspecific diagnosis of secondary OAis dependent on radiographic diag-nosis and is more sensitive in the

early stages of degeneration, beforeit progresses and remodeling occurs.Radiographic studies of both Cau-casian and Asian patients with andwithout OA suggest that a specificdiagnosis can be made. Disagree-

ment may arise in specific cases, butin a large series such cases shouldnot affect the overall conclusions.

It is noteworthy that studies ofthe Asian populations in San Fran-cisco and Hawaii showed similarprevalences of all types of hip ar-thritis in those who underwent THRbut virtually no underlying primaryOA. As the same radiographic cri-teria were applied to all races, thehigh incidence in Caucasians indi-

cates that the conditions are separa-ble at least 90% of the time.

The contribution of subclinicalSCFE to the overall incidence of pri-mary OA is small.34 In a study ofcadaver femora and pelves, the un-derlying anatomy was normal in83% of the specimens, and only 8%had subclinical SCFE. Interestingly,grade 2 OA developed in only 37%of the femora with subclinical SCFE;therefore, it appears that something

other than the anatomic deformityis the main etiologic factor underly-ing OA.

The results of comparison studiesof Caucasian, black, Native Ameri-can, and Hong Kong Chinese popu-lations; the joint replacement statis-tics; and the comparative rates ofTHR in American non-Caucasianpopulations indicate that primaryOA is a disease primarily of Cauca-sians of European ancestry. Inci-

dence rates do not appear to havechanged in the past four decades,suggesting that the etiologic factorshave not changed. Although somestudies suggest that factors such asobesity, high-performance athletics,strenuous occupations, and femoralneck anteversion may be contribu-tory to OA, there is also evidence tothe contrary. The minimal inci-dence of THR for primary OA inAmerican Asians compared with


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Caucasians living in a similar envi-ronment suggests a genetic etiology.

Apparently normal hip anatomyis present in more than 80% of pa-

tients in whom OA develops, andonly a small percentage of patientswith subclinical SCFE are subse-quently found to have OA. There-

fore, it is reasonable to postulate anunderlying defect in articular carti-lage or bone that leads to the even-tual development of OA.

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