A 58-year-old man from Mumbai with a 5-year history of right hip pain, worse on internal rotation and weight-bearing, presents to the orthopedic clinic. He has a sedentary job and is overweight (BMI 31). Examination shows restricted internal rotation and flexion of the right hip, positive FABER test, and antalgic gait. X-ray of the pelvis shows joint space narrowing, osteophytes at the femoral head–neck junction, and mild acetabular sclerosis. He has already tried NSAIDs for 6 weeks without adequate relief. Which of the following is the most appropriate next step in management?

Explanation

## Diagnosis: Primary Osteoarthritis of the Hip The clinical features are diagnostic: - Progressive pain over 5 years (mechanical pattern) - Restricted internal rotation and flexion (cardinal sign of hip OA) - Positive FABER test (flexion-abduction-external rotation; suggests intra-articular pathology) - Antalgic gait (pain-avoidance pattern) - Radiological confirmation: joint space narrowing, osteophytes, acetabular sclerosis - Risk factors: obesity (BMI 31), sedentary lifestyle ## Management Algorithm for Hip OA ```mermaid flowchart TD A[Hip OA confirmed on imaging]:::outcome --> B[Conservative management]:::action B --> C[NSAIDs + physiotherapy + weight loss]:::action C --> D{Adequate pain relief?}:::decision D -->|Yes| E[Continue conservative care]:::action D -->|No after 6-8 weeks| F[Intra-articular corticosteroid injection]:::action F --> G{Symptom improvement?}:::decision G -->|Yes| H[Repeat injections if needed + ongoing physio]:::action G -->|No| I[Consider total hip arthroplasty]:::action I --> J{Severe functional impairment + failed conservative care?}:::decision J -->|Yes| K[THR indicated]:::action J -->|No| L[Continue conservative management]:::action ``` **Key Point:** After failure of oral NSAIDs (6 weeks trial), intra-articular corticosteroid injection is the next step before considering surgical intervention [cite:Robbins 10e Ch 26]. **High-Yield:** Indications for intra-articular corticosteroid injection in hip OA: - Failure of adequate trial of oral analgesics/NSAIDs (6–8 weeks) - Functional impairment affecting quality of life - Patient not yet ready for or refusing surgery - Bridge therapy to delay or avoid arthroplasty **Clinical Pearl:** Hip OA is more disabling than knee OA because the hip is a weight-bearing joint and central to mobility. Intra-articular injection under ultrasound guidance has high accuracy and provides relief for 3–6 months in 60–70% of patients. **Mnemonic: RICE + Injection** — Rest, Ice, Compression, Elevation + Intra-articular injection (when conservative measures fail). ## Why Each Option Is Suboptimal | Option | Why It's Wrong | |--------|----------------| | Increase NSAID dose | Patient has already had 6 weeks of NSAID therapy without adequate relief. Escalating the dose risks GI toxicity without additional benefit. | | Intra-articular injection + physio + weight loss | **CORRECT** — This is the evidence-based next step. | | Immediate THR | Premature. THR is reserved for end-stage OA with severe functional impairment and failure of conservative measures (including injections). This patient has not yet exhausted non-surgical options. | | Methotrexate + prednisolone | Inappropriate. These are for inflammatory arthritis (RA), not degenerative OA. OA does not respond to immunosuppression. | **Warning:** Do NOT jump to surgery too early. THR is a major procedure with complications (infection, DVT, implant failure); it should be the last resort after conservative and minimally invasive options have been exhausted.