A 58-year-old Indian man with a 10-year history of primary osteoarthritis of the right hip presents with progressive pain and loss of internal rotation. He has tried NSAIDs and physiotherapy without sustained relief. On examination, the hip shows limited flexion, adduction, and internal rotation. X-ray confirms advanced OA with severe joint space narrowing and large osteophytes. His BMI is 28, and he has no contraindications to surgery. What is the most appropriate next step in management?

Explanation

## Management of Advanced Osteoarthritis: Surgical Indication ### Indications for Total Hip Arthroplasty (THA) **Key Point:** Total hip arthroplasty is the definitive treatment for advanced OA when conservative measures fail and the patient has significant functional impairment and pain affecting quality of life. ### Decision-Making Algorithm ```mermaid flowchart TD A[OA Hip with Pain & Functional Loss]:::outcome --> B{Conservative Therapy Failed?}:::decision B -->|No| C[NSAIDs, PT, Weight Loss]:::action B -->|Yes| D{Advanced OA on Imaging?}:::decision D -->|Mild-Moderate| E[Intra-articular Injection or Repeat Conservative]:::action D -->|Severe: JSN + Large Osteophytes| F{Patient Fit for Surgery?}:::decision F -->|Yes| G[Total Hip Arthroplasty]:::action F -->|No| H[Optimize Medical Management]:::action G --> I[Pain Relief + Improved Mobility]:::outcome ``` ### Why THA is Indicated Here | Criterion | Patient Status | Assessment | |-----------|----------------|------------| | **Duration of Symptoms** | 10 years | Chronic, established disease | | **Conservative Therapy** | NSAIDs + PT failed | Exhausted non-operative options | | **Imaging Severity** | Severe JSN + large osteophytes | Advanced structural damage | | **Functional Impairment** | Loss of ROM, pain with ADLs | Significant disability | | **Age** | 58 years | Acceptable for THA (modern implants last 15–20 years) | | **BMI** | 28 (overweight, not obese) | No absolute contraindication | | **Comorbidities** | None mentioned | Fit for surgery | | **Patient Motivation** | Seeking relief | Likely to comply with rehab | **Clinical Pearl:** The loss of internal rotation is a hallmark sign of advanced hip OA and indicates significant cartilage loss. This, combined with severe radiological changes and failed conservative therapy, makes THA the gold standard treatment. **High-Yield:** Modern THA has excellent outcomes: 85–95% implant survival at 10 years, significant pain relief, and improved function. Age alone is not a contraindication; fitness for surgery and realistic expectations are key. ### Contraindications to THA (Not Present Here) - Active infection or sepsis - Severe cardiopulmonary disease (uncontrolled) - Severe cognitive impairment (inability to comply with rehab) - Severe hip flexion contracture (>30°) — relative - Neuropathic joint (Charcot joint) — relative **Mnemonic:** **FIST** criteria for THA candidacy: - **F**ailed conservative therapy - **I**maging shows advanced OA - **S**evere symptoms affecting function - **T**olerable surgical risk [cite:Campbell's Operative Orthopaedics 13e Ch 5]