International
International Orthopaedics (SICOT) (1990) 14:29-30
Orthopaedics © Springer-Verlag 1990
Osteoarthritis of the hip and knee in Saudi Arabia A. Ahlberg, B. Linder, and T. A. Binhemd Departments of Orthopaedic Surgery and Family and Community Medicine, King Faisal University, College of Medicine and Medical Sciences, P. O. Box 2114, Dammam 31451, Saudi Arabia
Summary. The records of 4721 patients, who were registered at a Primary Health Care Centre in the Eastern Province of Saudi Arabia during a 18 month period, were reviewed. One hundred and sixty-six (3.5%) had osteoarthritis of the hip or knee. The ratio of hip to knee was 1:80 which is very low compared to other populations, and the possible causes for this are discussed.
t h a t osteoarthritis o f the hip is rare, while osteoarthritis o f the k n e e is m o r e c o m m o n , b u t n o studies h a v e b e e n c a r r i e d o u t to c o n f i r m this. T h e aim o f the p r e s e n t i n v e s t i g a t i o n w a s to d e t e r m i n e the p r o p o r t i o n a l rates o f osteoarthritis o f the hip a n d k n e e in a p r i m a r y health care c e n t r e in a t o w n in the E a s t e r n P r o v i n c e o f S a u d i Arabia.
R+sum~. Rbvision des dossiers de 4721 malades en-
Patients and methods
registrOs au Centre Primaire de Surveillance de la SantO, dans la province orientale de l'Arabie Saoudite, pendant une pOriode de 18 mois. 166 (3,5%) prbsentaient une arthrose de la hanche ou du genou. Le rapport hanche/genou Otait de 1/8o, ce qui est trOsfaible comparativement aux autres populations. Les causes possibles de cette diffbrence sont discutbes.
Introduction T h e i n c i d e n c e o f o s t e o a r t h r i t i s in v a r i o u s j o i n t s is r e l a t e d to g e o g r a p h i c a l a n d racial factors. M u l t i p l e j o i n t i n v o l v e m e n t is, f o r e x a m p l e , less c o m m o n in s o m e d e v e l o p i n g A f r i c a n p o p u l a t i o n s [5, 14, 161 a n d J a m a i c a n s [4] t h a n in C a u c a s i a n s . O s t e o a r t h r i t i s o f the hip has b e e n r e p o r t e d to h a v e a l o w e r i n c i d e n c e in C h i n e s e [8], S o u t h A f r i c a n b l a c k s [15], East I n d i a n s [131 a n d J a p a n e s e [91 c o m p a r e d to E u r o p e a n a n d A m e r i c a n whites [10]. Osteoa~rthritis o f the k n e e w a s f o u n d to be less common among Chinese than among Caucasians [8]. It is a g e n e r a l i m p r e s s i o n in the M i d d l e East
Q['[print requests to: A. Ahlberg
The records of patients with hip and knee problems, who were seen at the A1-Khobar Primary Health Care Centre from October 1986 to March 1988, were reviewed. The centre is run by the Department of Family and Community Medicine, King Faisal University, Dammam, and is open to all patients free of charge. During the 18 month period of the study, 4721 patients were registered. The diagnosis of osteoarthritis, and the classification idiopathic or secondary, was based on a medical history, physical examination, laboratory tests and radiographs according to the criteria given by the subcommittee on the Classification Criteria of Osteoarthritis, a subcommittee of the Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association [2]. One hundred and sixty-six patients were diagnosed as having osteoarthritis of the hip or knee. In 42 of these radiographs were not taken at the Primary Health Care Centre because recent films had been taken in another hospital, because the patient was pregnant or the diagnosis was clear. Standard projections with the patients lying down were the only radiographs taken. Patients with rheumatoid arthritis were excluded.
Results T h e d i s t r i b u t i o n o f the 166 p a t i e n t s into subsets is g i v e n in T a b l e 1. T h e h i p : k n e e ratio f o r i d i o p a t h i c osteoarthritis was 1:80 with m o r e f e m a l e s t h a n males. T h e m e a n age o f the w o m e n was 49.8 y e a r s a n d o f the m e n 61.4 years. T h e r e w e r e 163 p a t i e n t s with o s t e o a r t h r i t i s o f the k n e e a n d b o t h k n e e s w e r e a f f e c t e d in 114.
30
A. Ahlberg et al.: Osteoarthritis of the hip and knee in Saudi Arabia
Table 1. Distribution of the patients according to joint and type of OA Male
Female
Total
Hip
Idiopathic Secondary
2 1
0 0
2 1
Knee
Idiopathic Secondary
48 0
112 3
160 3
Three women had secondary osteoarthritis; two were post-traumatic (age 36 and 50 years) and one had Cushing's disease with genu valgum (age 37 years). Three patients had osteoarthritis of the hip; two were idiopathic (age 60 and 80 years) and one was secondary to avascular necrosis of the femoral head (age 51 years). The diagnosis was confirmed radiographically in these three cases. Discussion
Knowledge of geographical variations in the prevalence and pattern of distribution of a disease may contribute to an understanding of its aetiology, to the planning of treatment and prevention programmes, and to teaching protocols. This has been the case with cancer and heart disease [12]. Osteoarthritis is one of the most common joint diseases throughout the world and this kind of information is therefore of practical interest. The prevalence of osteoarthritis of the hip and knee cannot be estimated from our data because the population at risk is not known. The 3.5% incidence of osteoarthritis of the knee is not particularly high. The ratio of osteoarthritis of the hip and knee (1:80) indicates that osteoarthritis of the hip is extremely rare. Similar proportions have been reported from Jeddah (4:291, unpublished) and suggest that this figure might be representative for Saudi Arabia. Corresponding ratios can be estimated as 1:9 for Chinese Hong Kong [8], 1:3 for the United States [11], and 2:1 for Sweden [6]. These wide geographical variations probably result from several factors and, since osteoarthritis is a disease of the elderly, the age distribution in the area must be considered. Harris has suggested that almost all osteoarthritis of the hip is secondary to demonstrable deformities in the joint, the most common being mild acetabular dysplasia and "pistol-grip" deformity of the femoral head [7]. It is not known whether these deformities are very rare in Saudi Arabia, but the incidence of congenital instability of the hip in the newborn is the same as in Scandinavia or the United States [3]. Hoaglund et al. have suggested
that differences in the ratio of body weight to the size of femoral head might explain why osteoarthritis of the hip is less common among Japanese than among American whites [9], but this is not likely to be relevant in the Saudi Arabian population. The greater range of hip movement present in a Chinese population compared with a Caucasian has been suggested to explain the lower incidence of osteoarthritis of the hip among the Chinese [8]. This might also be a contributory factor to the low incidence of osteoarthritis of the hip in Saudi Arabia since the population has been shown to have a greater range of hip movement than a Swedish population [1], probably caused by differences in habits of daily life. References 1. Ahlberg A, Moussa M, A1-Nahdi M (1988) On geographical variations in the normal range of joint motion. Clin Orthop 234:229-231 2. Altman R, Asch E, Bloch D et al. (1986) Development of criteria for the classification and reporting of osteoarthritis. Arthritis Rheum 29: 1039-1049 3. A1-Umran K, Ahlberg A, Dawodu AH, E1-Mouzan MI, Ahmad FA (1988) Neonatal screening for hip instability: five years' experience. Ann Saudi Med 8 : 425-429 4. Bremer JM, Lawrence JS, Miall WE (1968) Degenerative joint disease in a Jamaican rural population. Ann Rheum Dis 27:326-332 5. Brighton SW, De La Harpe AL, van Staden DA (1985) The prevalence of osteoarthrosis in a rural African community. Br J Rheum 24:321-325 6. Danielsson L, Hernborg J (1970) Morbidity and mortality of osteoarthritis of the knee (gonarthrosis) in Malmo, Sweden. Clin Orthop 69:224-226 7. Harris WH (1986) Etiology of osteoarthritis of the hip. Clin Orthop 213:20-33 8. Hoaglund FT, Yau ACM, Wong WL (1973) Osteoarthritis of the hip and other joints in Southern Chinese in Hong Kong. J Bone Joint Surg [Am] 55:545-557 9. Hoaglund FT, Shiba R, Newberg AH, Leung KYK (1985) Diseases of the hip. A comparative study of Japanese Oriental and American White patients. J Bone Joint Surg [Am] 67:1380-1383 10. Kellgren JH, Lawrence JS (1961) Osteoarthrosis of the hip in random population samples. Proc X Congresso della Lega Internationale contra il Reumatismo, Rome, Italy 11. Kelsley JL, Patides H, Bisbee GE, White AA (1978) Musculo-skeletal disorders. Their frequency of occurrence and their impact on the population of the United States. Prodiet, New York 12. Mayer JD (1984) Medical geography. An emerging discipline. JAMA 251 : 2680-2683 13. Mukhopadhaya B, Barooah B (1967) Osteoarthritis of hip in Indians. An anatomical and clinical study. Indian J Orthop 1:55-62 14. Muller AS (1970) In: Population studies on the prevalence of rheumatic diseases in Liberia and Nigeria. Plasmans, The Hague, The Netherlands, p 105 15. Solomon L, Beighton P, Lawrence JS (1975) Rheumatic disorders of the South African Negro: Part II. Osteoarthritis. S Afr Med J 49:1737-1740 16. Solomon L, Beighton P, Lawrence JS (1976) Osteoarthritis in a rural South African Negro population. Ann Rheum Dis 35 : 274-278
International Orthopaedics (SICOT) (1990) 14:29-30
Orthopaedics © Springer-Verlag 1990
Osteoarthritis of the hip and knee in Saudi Arabia A. Ahlberg, B. Linder, and T. A. Binhemd Departments of Orthopaedic Surgery and Family and Community Medicine, King Faisal University, College of Medicine and Medical Sciences, P. O. Box 2114, Dammam 31451, Saudi Arabia
Summary. The records of 4721 patients, who were registered at a Primary Health Care Centre in the Eastern Province of Saudi Arabia during a 18 month period, were reviewed. One hundred and sixty-six (3.5%) had osteoarthritis of the hip or knee. The ratio of hip to knee was 1:80 which is very low compared to other populations, and the possible causes for this are discussed.
t h a t osteoarthritis o f the hip is rare, while osteoarthritis o f the k n e e is m o r e c o m m o n , b u t n o studies h a v e b e e n c a r r i e d o u t to c o n f i r m this. T h e aim o f the p r e s e n t i n v e s t i g a t i o n w a s to d e t e r m i n e the p r o p o r t i o n a l rates o f osteoarthritis o f the hip a n d k n e e in a p r i m a r y health care c e n t r e in a t o w n in the E a s t e r n P r o v i n c e o f S a u d i Arabia.
R+sum~. Rbvision des dossiers de 4721 malades en-
Patients and methods
registrOs au Centre Primaire de Surveillance de la SantO, dans la province orientale de l'Arabie Saoudite, pendant une pOriode de 18 mois. 166 (3,5%) prbsentaient une arthrose de la hanche ou du genou. Le rapport hanche/genou Otait de 1/8o, ce qui est trOsfaible comparativement aux autres populations. Les causes possibles de cette diffbrence sont discutbes.
Introduction T h e i n c i d e n c e o f o s t e o a r t h r i t i s in v a r i o u s j o i n t s is r e l a t e d to g e o g r a p h i c a l a n d racial factors. M u l t i p l e j o i n t i n v o l v e m e n t is, f o r e x a m p l e , less c o m m o n in s o m e d e v e l o p i n g A f r i c a n p o p u l a t i o n s [5, 14, 161 a n d J a m a i c a n s [4] t h a n in C a u c a s i a n s . O s t e o a r t h r i t i s o f the hip has b e e n r e p o r t e d to h a v e a l o w e r i n c i d e n c e in C h i n e s e [8], S o u t h A f r i c a n b l a c k s [15], East I n d i a n s [131 a n d J a p a n e s e [91 c o m p a r e d to E u r o p e a n a n d A m e r i c a n whites [10]. Osteoa~rthritis o f the k n e e w a s f o u n d to be less common among Chinese than among Caucasians [8]. It is a g e n e r a l i m p r e s s i o n in the M i d d l e East
Q['[print requests to: A. Ahlberg
The records of patients with hip and knee problems, who were seen at the A1-Khobar Primary Health Care Centre from October 1986 to March 1988, were reviewed. The centre is run by the Department of Family and Community Medicine, King Faisal University, Dammam, and is open to all patients free of charge. During the 18 month period of the study, 4721 patients were registered. The diagnosis of osteoarthritis, and the classification idiopathic or secondary, was based on a medical history, physical examination, laboratory tests and radiographs according to the criteria given by the subcommittee on the Classification Criteria of Osteoarthritis, a subcommittee of the Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association [2]. One hundred and sixty-six patients were diagnosed as having osteoarthritis of the hip or knee. In 42 of these radiographs were not taken at the Primary Health Care Centre because recent films had been taken in another hospital, because the patient was pregnant or the diagnosis was clear. Standard projections with the patients lying down were the only radiographs taken. Patients with rheumatoid arthritis were excluded.
Results T h e d i s t r i b u t i o n o f the 166 p a t i e n t s into subsets is g i v e n in T a b l e 1. T h e h i p : k n e e ratio f o r i d i o p a t h i c osteoarthritis was 1:80 with m o r e f e m a l e s t h a n males. T h e m e a n age o f the w o m e n was 49.8 y e a r s a n d o f the m e n 61.4 years. T h e r e w e r e 163 p a t i e n t s with o s t e o a r t h r i t i s o f the k n e e a n d b o t h k n e e s w e r e a f f e c t e d in 114.
30
A. Ahlberg et al.: Osteoarthritis of the hip and knee in Saudi Arabia
Table 1. Distribution of the patients according to joint and type of OA Male
Female
Total
Hip
Idiopathic Secondary
2 1
0 0
2 1
Knee
Idiopathic Secondary
48 0
112 3
160 3
Three women had secondary osteoarthritis; two were post-traumatic (age 36 and 50 years) and one had Cushing's disease with genu valgum (age 37 years). Three patients had osteoarthritis of the hip; two were idiopathic (age 60 and 80 years) and one was secondary to avascular necrosis of the femoral head (age 51 years). The diagnosis was confirmed radiographically in these three cases. Discussion
Knowledge of geographical variations in the prevalence and pattern of distribution of a disease may contribute to an understanding of its aetiology, to the planning of treatment and prevention programmes, and to teaching protocols. This has been the case with cancer and heart disease [12]. Osteoarthritis is one of the most common joint diseases throughout the world and this kind of information is therefore of practical interest. The prevalence of osteoarthritis of the hip and knee cannot be estimated from our data because the population at risk is not known. The 3.5% incidence of osteoarthritis of the knee is not particularly high. The ratio of osteoarthritis of the hip and knee (1:80) indicates that osteoarthritis of the hip is extremely rare. Similar proportions have been reported from Jeddah (4:291, unpublished) and suggest that this figure might be representative for Saudi Arabia. Corresponding ratios can be estimated as 1:9 for Chinese Hong Kong [8], 1:3 for the United States [11], and 2:1 for Sweden [6]. These wide geographical variations probably result from several factors and, since osteoarthritis is a disease of the elderly, the age distribution in the area must be considered. Harris has suggested that almost all osteoarthritis of the hip is secondary to demonstrable deformities in the joint, the most common being mild acetabular dysplasia and "pistol-grip" deformity of the femoral head [7]. It is not known whether these deformities are very rare in Saudi Arabia, but the incidence of congenital instability of the hip in the newborn is the same as in Scandinavia or the United States [3]. Hoaglund et al. have suggested
that differences in the ratio of body weight to the size of femoral head might explain why osteoarthritis of the hip is less common among Japanese than among American whites [9], but this is not likely to be relevant in the Saudi Arabian population. The greater range of hip movement present in a Chinese population compared with a Caucasian has been suggested to explain the lower incidence of osteoarthritis of the hip among the Chinese [8]. This might also be a contributory factor to the low incidence of osteoarthritis of the hip in Saudi Arabia since the population has been shown to have a greater range of hip movement than a Swedish population [1], probably caused by differences in habits of daily life. References 1. Ahlberg A, Moussa M, A1-Nahdi M (1988) On geographical variations in the normal range of joint motion. Clin Orthop 234:229-231 2. Altman R, Asch E, Bloch D et al. (1986) Development of criteria for the classification and reporting of osteoarthritis. Arthritis Rheum 29: 1039-1049 3. A1-Umran K, Ahlberg A, Dawodu AH, E1-Mouzan MI, Ahmad FA (1988) Neonatal screening for hip instability: five years' experience. Ann Saudi Med 8 : 425-429 4. Bremer JM, Lawrence JS, Miall WE (1968) Degenerative joint disease in a Jamaican rural population. Ann Rheum Dis 27:326-332 5. Brighton SW, De La Harpe AL, van Staden DA (1985) The prevalence of osteoarthrosis in a rural African community. Br J Rheum 24:321-325 6. Danielsson L, Hernborg J (1970) Morbidity and mortality of osteoarthritis of the knee (gonarthrosis) in Malmo, Sweden. Clin Orthop 69:224-226 7. Harris WH (1986) Etiology of osteoarthritis of the hip. Clin Orthop 213:20-33 8. Hoaglund FT, Yau ACM, Wong WL (1973) Osteoarthritis of the hip and other joints in Southern Chinese in Hong Kong. J Bone Joint Surg [Am] 55:545-557 9. Hoaglund FT, Shiba R, Newberg AH, Leung KYK (1985) Diseases of the hip. A comparative study of Japanese Oriental and American White patients. J Bone Joint Surg [Am] 67:1380-1383 10. Kellgren JH, Lawrence JS (1961) Osteoarthrosis of the hip in random population samples. Proc X Congresso della Lega Internationale contra il Reumatismo, Rome, Italy 11. Kelsley JL, Patides H, Bisbee GE, White AA (1978) Musculo-skeletal disorders. Their frequency of occurrence and their impact on the population of the United States. Prodiet, New York 12. Mayer JD (1984) Medical geography. An emerging discipline. JAMA 251 : 2680-2683 13. Mukhopadhaya B, Barooah B (1967) Osteoarthritis of hip in Indians. An anatomical and clinical study. Indian J Orthop 1:55-62 14. Muller AS (1970) In: Population studies on the prevalence of rheumatic diseases in Liberia and Nigeria. Plasmans, The Hague, The Netherlands, p 105 15. Solomon L, Beighton P, Lawrence JS (1975) Rheumatic disorders of the South African Negro: Part II. Osteoarthritis. S Afr Med J 49:1737-1740 16. Solomon L, Beighton P, Lawrence JS (1976) Osteoarthritis in a rural South African Negro population. Ann Rheum Dis 35 : 274-278
