A 68-year-old man from Delhi presents to the orthopaedic clinic with a 3-month history of progressive left hip pain, morning stiffness lasting 45 minutes, and difficulty walking. On examination, he has restricted internal rotation and abduction of the left hip, and a positive FABER test. Plain radiographs show joint space narrowing, osteophytes, and subchondral sclerosis of the left hip joint. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient presents with classic features of osteoarthritis of the hip: age >60, progressive pain, morning stiffness, restricted range of motion (especially internal rotation and abduction), and radiographic changes (joint space narrowing, osteophytes, sclerosis). ## Management Algorithm for Hip Osteoarthritis ```mermaid flowchart TD A[Hip OA confirmed on imaging]:::outcome --> B{Severity & functional impact?}:::decision B -->|Mild-moderate, preserved function| C[Conservative management]:::action B -->|Severe, refractory to conservative| D[Surgical intervention]:::action C --> E[NSAIDs + physiotherapy + lifestyle modification]:::action E --> F{Response at 6-8 weeks?}:::decision F -->|Good| G[Continue conservative care]:::outcome F -->|Poor| H[Consider intra-articular injection or surgery]:::decision D --> I[Total hip arthroplasty]:::action ``` ## Why Conservative Management First? **Key Point:** Even with radiographic evidence of osteoarthritis, the standard-of-care approach is to initiate conservative management BEFORE considering arthroplasty. Surgery is reserved for patients who fail medical management or have severe functional impairment. **High-Yield:** The NICE and American Academy of Orthopaedic Surgeons (AAOS) guidelines recommend: 1. NSAIDs (oral or topical) for pain control 2. Physiotherapy and exercise to maintain range of motion and strengthen periarticular muscles 3. Weight management to reduce joint loading 4. Activity modification 5. Reassessment at 6–8 weeks **Clinical Pearl:** Intra-articular corticosteroid injections are a bridge therapy for patients with inadequate response to NSAIDs, but are not first-line and should not be repeated more than 3–4 times per year due to risk of cartilage damage. ## Why NOT the Other Options? - **Immediate arthroplasty:** This patient has not exhausted conservative options. Hip replacement is major surgery with a 10–15 year lifespan for the prosthesis; early surgery may necessitate revision in the future. - **MRI:** Diagnosis is already confirmed on plain radiographs. MRI adds no diagnostic value and is not indicated. - **Corticosteroid injection alone:** While reasonable as a second-line option after NSAIDs fail, it is not the initial step and should be combined with physiotherapy.