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Hip osteoarthritis — MSRA MCQ

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HardHip and GroinHip osteoarthritisMSRA

A 67-year-old woman with established right hip osteoarthritis reports worsening groin pain over 6 months. She now walks less than 50 metres, cannot put on socks independently and has stopped attending social activities because of pain. She has completed a 12-week supervised therapeutic exercise programme, uses a walking stick and has engaged with weight-management support. Paracetamol was ineffective. Oral NSAIDs are unsuitable because her eGFR is 36 mL/min/1.73 m². An image-guided intra-articular corticosteroid injection gave relief for 3 weeks only. She has a BMI of 42 kg/m², smokes 10 cigarettes daily and has type 2 diabetes with an HbA1c of 72 mmol/mol. There are no red-flag features or symptoms suggesting an alternative diagnosis. She wishes to consider hip replacement but asks whether she must first reach a specified BMI and stop smoking before referral. What is the most appropriate next step in primary care?

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

Reveal the answer and explanation

Correct answer: C — Refer for orthopaedic assessment for joint replacement now, while offering support to optimise smoking, weight and glycaemic control

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

Her hip osteoarthritis is substantially affecting quality of life and function, and appropriate non-surgical management has been ineffective or unsuitable: she has completed therapeutic exercise and weight-management support, paracetamol was ineffective, oral NSAIDs are unsuitable because of chronic kidney disease, and the previous corticosteroid injection gave only brief benefit. She should therefore be referred now for consideration of joint replacement. NICE advises against excluding people from referral because of obesity, smoking or comorbidity. These factors may affect operative risk and should prompt optimisation and shared decision-making, but they are not reasons to impose a primary-care threshold before referral. A is incorrect because referral should be based on clinical assessment rather than a numerical score; routine imaging is not required to guide non-surgical management. B wrongly treats modifiable risk factors as exclusion criteria. C is plausible because corticosteroid injection can provide short-term relief, but it should not delay referral where symptoms already substantially impair quality of life and non-surgical options have not provided adequate control. E is incorrect because NICE advises not to offer strong opioids for osteoarthritis, as harms outweigh benefits.

Reference: NICE NG226: Osteoarthritis in over 16s: diagnosis and management — Recommendations (19 October 2022) — https://www.nice.org.uk/guidance/NG226/chapter/recommendations NICE NG226: Osteoarthritis in over 16s: diagnosis and management — Intra-articular injections (19 October 2022) — https://www.nice.org.uk/guidance/NG226/chapter/recommendations NICE NG226: Osteoarthritis in over 16s: diagnosis and management — Pharmacological management (19 October 2022) — https://www.nice.org.uk/guidance/NG226/chapter/recommendations