Heel lifting as a conservative therapy for osteoarthritis of the hip: based on the rationale of Pauwels' intertrochanteric osteotomy
S. Ohsawa *
R. Ueno *
Patients with osteoarthritis of the hip were treated with a conservative therapy of heel lifting. Orthoses were applied on 35 hips in 33 subjects and the cases were followed for 23 months on average. Dramatic pain relief was reported, but the time required to reduce or completely relieve pain increased according to the stage of osteoarthritis. The radiological results were not satisfactory.
During the follow-up, only two hips showed improvement, 22 showed no change, and 11 deteriorated. The mechanism of heel lifting in relation to the hip joint was analysed, showing that pelvic obliquity was achieved and the trunk stabilized. In conclusion this simple orthosis was effective as a palliative therapy for osteoarthritis of the hip.
A palliative therapy is proposed for osteoarthritis of the hip. For mothers of young children and others who cannot spend time in the hospital for rehabilitation after operation, a treatment was devised to relieve hip pain without medication such as non-steroidal anti-inflammatory drugs.
Operations for osteoarthritis of the hip were developed in the latter half of the 20th century. Among them was the intertrochanteric osteotomy which was developed by Pauwels (Pauwels, 1976), and from which good results have been reported (Ohsawa, 1994). The indications for osteotomy are as follows: valgus osteotomy is indicated when congruence improves with adduction of the hip (Fig.l). Varus osteotomy is performed when the congruence improves with abduction of the hip (Fig. 2). The authors proposed instead to use lifting to tilt the pelvis. The raised side would produce hip valgus on that side and raising of the contralateral side would produce hip varus (Fig. 3). As a result, this lifting could be as effective as intertrochanteric osteotomy. Clinical tests were performed to test this hypothesis (Ohsawa and Ueno, 1993).
Materials and methods
Indication and application
The orthosis was offered to patients who refused operation but suffered from hip pain from osteoarthritis (Table 1). The procedure was applicable to all stages of osteoarthritis. When the joint congruence improved with adduction of the hip, a valgus effect on the hip was necessary (Fig. 1). A raise was therefore applied to the affected leg. The amount of lift was the same as that of the discrepancy of the functional limb length, so that patients felt that both limbs were the same length. When the joint congruence improved with abduction of the hip, a varus effect on the hip was necessary (Fig. 2). A raise was therefore applied to the contralateral leg. The maximum amount of lift was around 1.5cm, because a higher lift caused the shoe to slip off (Fig. 4).
Methods of analysis
Clinically, the Merle d'Aubigné hip score was used (Merle d'Aubigné and Postel, 1954), along with pelvic radiography. Patients were analysed in the standing position using a radiograph of the pelvis, and body centre analysis with and without heel lifting. Motion analysis was carried out on patients in walking.
Standing position: The angle between the pelvis and the femur was measured for all patients using a pelvic radiograph in the standing position with and without a raise (Fig. 5). The movement of the body centre of the 25 patients was studied using a body centre analyzer (San'ei, 1G06, Japan). The patients stood for 30 seconds in relaxed open-eye condition with and without the raise. The body sway was defined as the absolute value of A minus B shown in Fig. 6.
Gait analysis: Twenty-two patients were assessed. In measuring the motion in the frontal plane, it was assumed that the gait was similar to walking in place. A two-dimensional motion analyzer was used (EMTEK, MVA-2000, Japan). The patients had marks on both shoulders, iliac crests, patellae, and ankles and positional data was collected for five seconds (Fig. 7). The effect of heel lifting in walking was estimated by the angle between the pelvis (the line of both iliac crests) and thigh (the line of the iliac crest and the patella) in the stance phase of the test (Fig. 8). Trunk instability was measured by the relative vertical and horizontal movements of the points of the shoulder and the iliac crest.
Patients: A total of 33 cases (two men and 31 women), involving 35 hips were treated by heel lifting (Table 1). Twenty-four hips needed a valgus effect, so the affected leg was fitted with a raise. Eleven hips needed a varus effect, so the contralateral leg was fitted with a raise. Two cases suffered from osteoarthritis bilaterally. One hip needed a valgus effect and the other needed a varus effect. Therefore both hips were treated using a single raise. Another case was treated by a raise to produce varus effect but the hip deteriorated and the indication changed requiring a valgus effect, so the hip was treated using two methods. The average age of the patients was 51 years old. Each case was followed for 23 months on average. Statistical analysis of the t-test was carried out.
Twenty-seven cases used a raise at the final follow-up. Two cases did not use one because of absence of hip pain. One stopped using the raise because contralateral pain occurred. Four hips were operated on. Two hips were treated by intertrochanteric osteotomy, and the other two by total hip arthroplasty. The time required for hip pain to decrease or disappear after the heel lifting is shown in Table 2. There is a relationship between the time it took hip pain to decrease or disappear and the stage of osteoarthritis.
Clinical hip scores increased with improvement of pain scores, but range of hip motion and gait ability did not change. Final total hip scores and pain scores significantly improved. The radiological changes of the osteoarthritis before lifting and at the final follow-up were estimated. Two hips in the late stage of coxarthritis improved, but others deteriorated (11 hips) or showed no change (22 hips) at the final follow-up.
Pelvic radiographs in the standing position with and without heel lifting are shown in Fig. 5. The angle decreased on the raised side and a valgus effect was observed in the hip. The angle increased on the contralateral side with a varus effect at the hip. In body centre analysis, fourteen out of 26 patients regained stability by heel lifting, but the other 12 patients did not.
Motion analysis of the angle between the pelvis and the thigh was carried out as shown in Fig. 8. In the patients whose hips needed a valgus effect, the angle between the pelvis and the thigh was not changed by the raise and 12 cases out of 15 did not show any effect in the motion analysis. However in the patients whose hips needed a varus effect, the angle between the pelvis and the thigh was changed by the lift; 5 cases out of 7 were affected by the lift. Some 15 patients had their trunks stabilized by lifting and seven patients did not in the motion analysis.
The results showed that lifting did not change the natural course of the osteoarthritis. This orthosis is not considered by the authors to be the best method as a conservative therapy, but lifting of the heel is very simple and effective for relief of hip pain and can postpone operative treatment. The orthosis could be a palliative treatment for people who cannot take time from a job or child care and it obviates the need for medication, which can be a cause of gastric or duodenal ulcers. Other orthoses are available but they are large and restrict patients' activity (Holtmann, 1958; Kawamura, 1983).
The biomechanical analyses revealed that some patients were not clearly stabilized by the lift. Each method of analysis is compared with the clinical results as shown in Fig. 10 where the solid bar denotes no improvement in the pain score and the empty bar improvement by one or more points. The figure showed the relationship between biomechanical effects and pain scores at the final follow-up. This figure supported the hypothesis that the heel raise affected the stability of the body and improved the hip joint position and also justified the indications according to the rationale of Pauwels' osteotomy.
The more advanced stage of the disease, the longer it took to reduce hip pain. The orthosis did not cause lumbar pain. It even provided lumbar pain relief, because the limb length discrepancy was decreased by the orthosis. This phenomenon would also support the application of a raise for patients with a hip-spine syndrome (Offierskl and Macnab, 1983). The orthosis is simple and had a good effect on hip pain, but did not affect the natural course of osteoarthritis of the hip joint.
The authors are grateful to Ms. Y. Takemori for preparing the manuscript.
- Hohmann G (1958). Orthopaedishe technik.-Stuttgart: Ferdinand Enke Verlag, p159-167.
- Kawamura T (1983). Development of the S-form hip brace of Wakayama Medical College type for osteoarthritis of the hip. J Jap Orthop Assoc 57, 1665-1679.
- Merle d'Aubigné R, Postel M (1954). Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg 36A, 451 -475.
- Offierski CM, Macnab I (1983). Hip-spine syndrome. Spine 8,316-321.
- Ohsawa S, Ueno R(1993). Orthotic treatment of coxarthritis. Bessatsu Seikeigeka 24, 166-169 (in Japanese).
- Ohsawa S, Matsushita S, Ueno R (1994). Joint preserving operations for elderly patients with advanced and late-stage coxarthritis. Arch Orthop Trauma Surg 113, 302-307.
- Pauwels F (1976). Biomechanics of the normal and diseased hip: theoretical foundation, technique and results of treatment: an atlas.- Berlin: Springer Verlag, p129-261.