A 36-year-old woman comes to the office due to joint pain during sexual intercourse. Over the past year, she has had difficulty during intercourse due to limited range of motion of the right hip and pain radiating from the hip to the low back. The patient has tried a number of medications, including acetaminophen and naproxen, without relief. In addition to bilateral osteoarthritis of the hips and knees, medical history is notable for morbid obesity, obstructive sleep apnea, and mixed hyperlipidemia. For the past 6 months, the patient has been in a supervised weight-loss program consisting of a modified diet and orlistat and has lost 3 kg (6.6 lb). BMI is 41 kg/m². Physical examination shows limited abduction of the right leg due to pain. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_c0b2_660f_8f63_fd4d9f8365f5_MD0005_00 This patient has refractory hip pain due to osteoarthritis in the setting of morbid obesity. Conservative measures, including exercise, acetaminophen, and nonsteroidal anti-inflammatory drugs, are usually attempted first but may not provide adequate long-term relief. In such patients, surgical intervention (eg, joint replacement) may be needed. However, morbid obesity is a relative (although not absolute) contraindication to joint replacement and is associated with an increased risk of perioperative complications. Although aggressive weight loss may improve pain control and reduce surgical risk (eg, joint replacement), this patient has had appropriate management with dietary modification and weight-loss medication without significant weight loss. Bariatric surgery should therefore be considered, and is appropriate for patients with BMI >40 kg/m² (as in this patient) or those with BMI >35 kg/m² accompanied by an obesity-related comorbidity (eg, uncontrolled diabetes mellitus). Additional trials of other weight-loss medications (eg, bupropion/naltrexone) can also be considered and may be attempted concurrently with bariatric surgery referral. (Choices A and C) Hip resurfacing arthroplasty consists of trimming the femoral head and capping it with a metal covering, as well as replacing damaged bone with a metal shell. It is most successful in young, active men. However, it is less effective long term than joint replacement. If more aggressive weight-loss measures are not effective in relieving this patient's pain, orthopedic interventions can be considered. (Choice D) Soft pads placed under the back may provide some short-term relief for this patient, but obesity is the underlying cause of her symptoms. Weight loss would provide better long-term relief. (Choice E) This patient should be counseled to continue a low-calorie diet, but so far this has failed. Physical therapy may provide some functional improvement but would not alter her underlying disease course. Tricyclic antidepressants (eg, amitriptyline) can sometimes help in long-term pain management but are associated with weight gain. Educational objective: Morbid obesity is associated with an increased risk of complications in joint replacement surgery. Aggressive weight loss in obese patients with osteoarthritis can provide improved pain control. Weight-loss surgery should be considered for patients with BMI >40 kg/m² or with obesity-related comorbidity and BMI >35 kg/m². References: The benefits of bariatric surgery in obese patients with hip and knee osteoarthritis: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/21883871)

A 36-Year-Old Woman Comes to the Office Due to Joint