A 75-year-old man comes to the physician because of bilateral groin pain that is worse on the right side than the left. The pain is aggravated by any type of prolonged weight bearing. He feels particularly stiff in the hips in the mornings and after sitting in one place for a few hours. He was prescribed physical therapy and tramadol 4 months ago. After some temporary relief, he now feels more pain throughout the day, which limits his daily activities. He also received physical therapy last year, which provided only temporary relief. He denies any pain or swelling in his other joints or systemic symptoms. His daughter who accompanies him states that he had recently complained of dizziness.
His other medical problems include type 2 diabetes mellitus, hypercholesterolemia, peripheral vascular disease, and benign prostatic hyperplasia. The patient lives at home by himself. His medications include aspirin, metformin, glipizide, hydrochlorothiazide, lisinopril, acetaminophen, and tramadol.
His vital signs are within normal limits. Range of motion of the spine is normal and without pain. There is no scoliosis or excessive kyphosis. There is significant reduction in internal and external rotation at the hip joints accompanied by pain.
Complete blood count and basic metabolic panel are unremarkable. ESR is 15 mm/hr.
A radiograph of the right hip joint is shown here.
Which of the following is the most appropriate next step in this patient's management?

Question

A 75-year-old man comes to the physician because of bilateral groin pain that is worse on the right side than the left.  The pain is aggravated by any type of prolonged weight bearing.  He feels particularly stiff in the hips in the mornings and after sitting in one place for a few hours.  He was prescribed physical therapy and tramadol 4 months ago.  After some temporary relief, he now feels more pain throughout the day, which limits his daily activities.  He also received physical therapy last year, which provided only temporary relief.  He denies any pain or swelling in his other joints or systemic symptoms.  His daughter who accompanies him states that he had recently complained of dizziness.
His other medical problems include type 2 diabetes mellitus, hypercholesterolemia, peripheral vascular disease, and benign prostatic hyperplasia.  The patient lives at home by himself.  His medications include aspirin, metformin, glipizide, hydrochlorothiazide, lisinopril, acetaminophen, and tramadol.
His vital signs are within normal limits.  Range of motion of the spine is normal and without pain.  There is no scoliosis or excessive kyphosis.  There is significant reduction in internal and external rotation at the hip joints accompanied by pain.
Complete blood count and basic metabolic panel are unremarkable.  ESR is 15 mm/hr.
A radiograph of the right hip joint is shown here.
Which of the following is the most appropriate next step in this patient's management?

Quizplus · Accepted Answer

11ec193a_991a_06a2_853d_519b5e7a37b4_MD0002_00 This patient's presentation is consistent with advanced noninflammatory osteoarthritis (OA) with severe pain that limits his activities of daily life. Hip OA patients typically present after age 50 with groin pain and impaired internal rotation (<15°) and hip flexion (<115°). Diagnosis also requires two of the following: ESR < 20 mm/hr, x-rays showing osteophytes (femoral or acetabular), or joint space narrowing (superior, axial, or medial) on hip radiographs. This patient's x-ray shows a complete loss of joint space, osteophytes, and sclerosis of the acetabular articular surfaces and the head of the femur. Nonpharmacologic treatments (e.g., weight loss, wedged shoe insoles) are recommended first and are effective in some patients. Acetaminophen is recommended as a first-line therapy for noninflammatory OA followed by NSAIDs as needed in patients with persistent symptoms. The next step is to try intraarticular steroid injections followed by intraarticular hyaluronic acid or short-term opioids (e.g., oxycodone) in refractory patients. Patients with persistent symptoms and significant impairment (such as this patient) usually require total hip replacement. Surgery should be performed early before the patient develops significant deformities, joint instability, contractures, or muscular atrophy. (Choices A and C) Tramadol is preferred over NSAIDs in patients with renal impairment; however, it can cause dizziness and confusion. Since this patient already has dizziness, increasing the dose is not appropriate. In addition, adding an opioid can cause more dizziness and confusion in this elderly patient. (Choice B) Intraarticular hyaluronic acid products are approved for knee osteoarthritis, but are more useful in OA of recent onset rather than severe advanced OA. These products have been studied for use in other joints, but are not yet FDA approved. (Choice E) Oral corticosteroids are not beneficial in OA; they are more useful in polymyalgia rheumatica (PMR). However, PMR usually presents with symmetric bilateral stiffness in the hips and shoulders as well as an elevated ESR. Educational objective: Osteoarthritis of the hip presents with hip pain, limited range of motion, and x-rays showing joint space narrowing. Acetaminophen is usually the first-line therapy for noninflammatory OA, followed by NSAIDS and intraarticular steroid injections. Patients with persistent pain or severe impairment typically require early surgical therapy with total hip replacement. __________ References: Osteoarthritis: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/22230308) Therapeutic trajectory following intra-articular hyaluronic acid injection in knee osteoarthritis--meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21443958)

A 75-Year-Old Man Comes to the Physician Because of Bilateral