A 42-year-old woman from Mumbai presents with a 6-month history of progressive pain in the left hip, groin, and medial thigh. She reports pain on internal rotation and flexion of the hip. Clinical examination reveals restricted internal rotation and a positive FABER test. Plain radiographs show joint space narrowing and osteophytes. MRI confirms early osteoarthritis with intact labrum. She has failed 3 months of conservative management (NSAIDs, physiotherapy, weight loss). What is the most appropriate next step in management?

Explanation

## Management of Early Hip Osteoarthritis — Next Step After Conservative Failure ### Clinical Assessment This patient has **early hip osteoarthritis (OA)** with: - Radiographic changes (joint space narrowing, osteophytes) - Intact labrum on MRI (no structural labral pathology) - Failed conservative management (3 months of NSAIDs, physiotherapy, weight loss) - Preserved hip function (no mention of severe functional loss) **Key Point:** The management ladder for hip OA progresses: conservative therapy → intra-articular injections → surgical interventions (arthroscopy/osteotomy) → arthroplasty. Intra-articular corticosteroid injection is the next evidence-based step after failed conservative management in early-to-moderate OA. ### Intra-Articular Corticosteroid Injection **Indications:** - Failed conservative management (NSAIDs, physiotherapy, weight loss) - Early-to-moderate OA (Kellgren-Lawrence grade I–II) - Intact joint anatomy (no severe cartilage loss) - Patient desire to delay or avoid surgery **Mechanism:** - Corticosteroids reduce synovial inflammation and pain - Provides symptomatic relief for 3–6 months (sometimes longer) - Allows continued physiotherapy and functional improvement - Can be repeated (typically up to 3–4 injections per year) **High-Yield:** Ultrasound-guided injection improves accuracy and reduces complications compared to landmark-based injection. Success rate is 60–70% in early OA. ### Why NOT the Other Options? | Option | Why Wrong | |--------|----------| | **Immediate THR** | Patient is only 42 years old with early OA. THR is reserved for advanced OA (Kellgren-Lawrence grade III–IV) with severe functional loss. Early THR in young patients leads to revision surgery within 15–20 years due to implant wear. | | **Repeat MRI in 6 months** | Imaging surveillance without intervention is inappropriate after failed conservative management. Patient is symptomatic and requires active treatment, not observation. | | **Hip arthroscopy + labral debridement** | The labrum is intact on MRI; there is no labral pathology to address. Arthroscopy is indicated for labral tears, FAI, or loose bodies — not for isolated OA with an intact labrum. | **Clinical Pearl:** Hip OA in a 42-year-old is relatively young-onset. Preserving the native hip joint as long as possible is crucial. Intra-articular injections bridge the gap between conservative therapy and arthroplasty, potentially delaying or avoiding surgery for years. **Warning:** Do not confuse **femoroacetabular impingement (FAI)** with primary OA. FAI may require arthroscopic osteoplasty; however, this patient has OA with an intact labrum, not FAI. [cite:Uppal et al. Hip Osteoarthritis Management Guidelines, American Academy of Orthopaedic Surgeons 2023]