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Hip osteoarthritis — MSRA MCQ

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HardHip and GroinHip osteoarthritisMSRA

A 61-year-old school caretaker has a 20-month history of activity-related right groin pain and brief morning stiffness. Hip internal rotation is restricted and reproduces the pain. There is no trauma, rapid deterioration, prolonged stiffness or systemic illness. Plain radiography shows mild-to-moderate osteoarthritic change. Pain regularly wakes him, he has stopped working, and he uses a walking stick outside. He has completed four months of supervised therapeutic exercise and supported weight management without adequate improvement. Topical NSAIDs have been ineffective. Oral NSAIDs are unsuitable because he has chronic kidney disease and previous myocardial infarction. His BMI is 40 kg/m², he smokes, and his HbA1c is 78 mmol/mol. His Oxford Hip Score falls outside the eligibility range displayed by the local electronic referral pathway. He understands that his comorbidities may increase operative risk but requests a surgical opinion. Which is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Refer for joint replacement assessment and continue modifiable-risk optimisation in parallel.

Explanation lettering: D = shown as C · E = shown as D · C = shown as E

This is clinically typical hip osteoarthritis: he is over 45, has activity-related pain, brief morning stiffness and painful restriction of hip movement, with no atypical features requiring further diagnostic imaging. The modest radiographic changes do not invalidate the diagnosis because structural changes correlate poorly with symptom severity. His pain and functional loss substantially affect quality of life, and appropriate non-surgical management has been ineffective or is unsuitable. NICE therefore supports referral for joint replacement assessment. The Oxford Hip Score must not be used as a referral gatekeeper. Obesity, smoking and comorbidities, including diabetes, may alter perioperative risk but must not exclude him from referral; optimisation should proceed alongside specialist assessment. A is inappropriate because further weight loss is not a prerequisite for referral, although support should continue. B recognises genuine operative risks but incorrectly makes their prior optimisation a condition of referral rather than surgery. C is unnecessary because there are no atypical features and imaging severity should not determine referral. D would be appropriate if core treatment had not received an adequate trial, but he has completed prolonged supervised exercise and weight-management support, with limited suitable analgesic options. Referral initiates individualised surgical assessment and shared decision-making; it does not commit him to an operation.

Reference: Osteoarthritis in over 16s: diagnosis and management — Recommendations (Published 19 October 2022; checked 15 August 2026) — https://www.nice.org.uk/guidance/NG226/chapter/recommendations Osteoarthritis in over 16s — Quality statement 1: Diagnosis (Last updated 19 October 2022; checked 15 August 2026) — https://www.nice.org.uk/guidance/qs87/chapter/Quality-statement-1-Diagnosis Osteoarthritis in over 16s — Quality statements (Last updated 19 October 2022; checked 15 August 2026) — https://www.nice.org.uk/guidance/qs87/chapter/Quality-statements