What are the treatment options for an 87-year-old patient with severe left hip osteoarthritis (OA) and osteopenia who fell onto their left hip, resulting in pain and stiffness, but no acute fracture?

Treatment Options for an 87-Year-Old Patient with Severe Left Hip Osteoarthritis

For an 87-year-old patient with severe left hip osteoarthritis, pain, and stiffness following a fall, a multimodal treatment approach combining non-pharmacological and pharmacological interventions is strongly recommended, with total hip arthroplasty as a definitive option for those with appropriate functional status and comorbidity profile. 1

Initial Assessment Following Fall

• A comprehensive multidisciplinary assessment should be performed to evaluate for common modifiable variables including malnutrition, electrolyte disturbances, anemia, and cardiac/pulmonary diseases 2
• Although imaging shows no acute fracture, the patient should be evaluated for fall risk factors including gait, balance, lower limb strength, medication review, and environmental factors 2
• The presence of osteopenia noted on imaging warrants bone health assessment and consideration of secondary fracture prevention strategies 2

Non-Pharmacological Interventions

Exercise Therapy (Strongly Recommended)

• Exercise is the cornerstone of osteoarthritis management and should be implemented even in patients with pain 1
• Specific recommendations include:
  • Aerobic exercises such as walking or stationary cycling at a level tolerable to the patient 1
  • Strengthening exercises focusing on hip and knee muscles using submaximal resistance 1
  • Balance exercises to improve stability and potentially reduce fall risk 1
  • Aquatic exercises may be particularly beneficial for patients with mobility limitations 3

Self-Management and Education

• Self-efficacy and self-management programs are strongly recommended to help the patient understand their condition and develop coping strategies 1
• Patient education should include information about osteoarthritis, pain management techniques, and joint protection measures 1

Physical Modalities

• Application of thermal therapies (heat or cold) can provide temporary pain relief 1, 3
• Consider referral to physical therapy for supervised exercise, which is more effective than home-based programs alone 1

Assistive Devices

• Walking aids (cane or walker) should be considered to improve stability and reduce joint loading 4, 3
• Appropriate footwear with cushioning and support can help reduce impact on the affected joint 3

Pharmacological Management

First-Line Options

• Acetaminophen (up to safely tolerated doses) for pain relief with minimal systemic effects 1, 5
• Topical NSAIDs can provide localized pain relief with fewer systemic side effects than oral NSAIDs 3

Second-Line Options

• Oral NSAIDs (such as ibuprofen) at the lowest effective dose and for the shortest duration possible, with careful consideration of the patient's age and comorbidities 6, 7
• NSAIDs should be used cautiously in this 87-year-old patient due to increased risk of gastrointestinal, cardiovascular, and renal adverse effects 6

Additional Options

• Intra-articular corticosteroid injections can provide short-term pain relief for acute exacerbations 7, 3
• Duloxetine may be considered for pain management if other options are insufficient 7
• Opioids should be avoided due to their unfavorable risk-benefit profile, particularly in elderly patients 7

Consideration for Surgical Management

• Total hip arthroplasty (THA) should be strongly considered given the:
  • Complete obliteration of joint space on imaging
  • Severe symptoms affecting quality of life
  • Failure of conservative management 1
• THA has demonstrated functional benefits over other surgical options in properly selected patients with osteoarthritis 1
• Surgical decision should account for the patient's age, comorbidities, and functional status prior to the fall 1
• If surgery is pursued, orthogeriatric comanagement is recommended to optimize outcomes and reduce complications 2

Bone Health Management

• Given the presence of osteopenia, evaluation and management of bone health is important 2, 8
• Consider:
  • Calcium and vitamin D supplementation 2
  • Bone density testing 8
  • Possible bisphosphonate therapy to reduce fracture risk 2, 9
• Note that osteoarthritis and osteoporosis often have an inverse relationship, but both conditions can coexist, especially in elderly patients 8

Special Considerations for This Patient

• Advanced age (87 years) increases surgical risks but should not automatically exclude THA if the patient was previously independent and has good potential for rehabilitation 1
• The absence of fracture despite the fall and osteopenia suggests the need for fall prevention strategies 2
• Weight-bearing as tolerated should be encouraged to maintain mobility and prevent deconditioning 2