What is the best treatment approach for a patient with a history of broken hip, arthritis, and internal fixation devices in the hip?

Management of Hip Arthritis with Prior Fracture and Internal Fixation

For a patient with established hip arthritis, prior hip fracture with internal fixation (ten pins), and confirmed MRI diagnosis, the optimal treatment approach combines non-pharmacological interventions with NSAIDs as first-line therapy, progressing to total hip arthroplasty when conservative measures fail to control symptoms. 1

Initial Conservative Management

Begin with a multimodal non-pharmacological and pharmacological approach, as optimal management requires combining both treatment modalities. 1

Non-Pharmacological Interventions (First-Line)

• Implement regular education about the condition, prognosis, and self-management strategies 1
• Prescribe land-based cardiovascular and/or resistance exercise programs 1
• Consider aquatic exercise as an alternative or adjunct 1
• Provide walking aids (cane or stick) to reduce mechanical stress on the affected hip 1
• Recommend weight reduction if the patient is overweight or obese, as this addresses a key hip risk factor 1
• Refer to physical therapy for mild-to-moderate symptomatic hip osteoarthritis, which can improve pain and physical function 1, 2
• Manual therapy combined with supervised exercise shows high-quality evidence for improving pain, hip range of motion, and physical function 2

Pharmacological Management (Stepwise Approach)

Step 1: Acetaminophen (Paracetamol)

• Start with acetaminophen up to 4 grams daily as the oral analgesic of first choice for mild-moderate pain due to its efficacy and safety profile 1
• If successful, acetaminophen is the preferred long-term oral analgesic 1

Step 2: NSAIDs (If Acetaminophen Inadequate)

• Add or substitute oral NSAIDs at the lowest effective dose when patients respond inadequately to acetaminophen 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1
• NSAIDs should be used when not contraindicated for symptomatic hip osteoarthritis 1
• Naproxen has demonstrated comparable efficacy to aspirin and indomethacin for controlling osteoarthritis symptoms, with less frequent and less severe gastrointestinal and nervous system adverse effects 3

Step 3: Alternative Analgesics

• Consider opioid analgesics (with or without acetaminophen) only as alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 1
• However, oral opioids should generally not be used for treatment of symptomatic hip osteoarthritis based on consensus evidence 1

Interventional Options

• Intra-articular corticosteroid injections (guided by ultrasound or X-ray) may be considered for patients with symptom flares unresponsive to analgesics and NSAIDs 1
• Do NOT use intra-articular hyaluronic acid injections, as high-quality evidence shows they should not be considered for symptomatic hip osteoarthritis 1

Special Considerations for Prior Hip Fracture with Hardware

The presence of internal fixation devices (ten pins) from prior hip fracture creates unique considerations:

• The existing hardware does not preclude conservative management or eventual arthroplasty 1
• MRI confirmation of arthritis diagnosis is appropriate and helps rule out occult fractures or hardware complications 4
• The prior fracture history increases the likelihood that arthritis has developed, particularly if it was an intracapsular fracture, which is associated with longer-term arthritis even after treatment 1

Indications for Surgical Intervention

Total hip arthroplasty should be considered when:

• Patients have radiographic evidence of hip osteoarthritis with refractory pain and disability despite conservative management 1
• Conservative treatments including NSAIDs, physical therapy, and activity modification have failed to provide adequate symptom relief 1, 5
• The patient's quality of life is significantly impaired by hip pain and functional limitations 1

For properly selected patients with underlying osteoarthritis, total hip arthroplasty may provide functional benefit over hemiarthroplasty, though with increased risk of complications 1

Cemented arthroplasty is strongly recommended over uncemented arthroplasty, as it improves hip function and is associated with lower residual pain postoperatively 1

Treatment Algorithm Summary

1. Start with combined non-pharmacological interventions (exercise, education, weight management, assistive devices) plus acetaminophen 1
2. If inadequate response after 3 months, add or substitute NSAIDs at lowest effective dose 1, 5
3. Consider intra-articular corticosteroid injection for acute flares 1
4. If symptoms remain refractory after comprehensive conservative management, proceed to total hip arthroplasty evaluation 1, 5

Critical Pitfalls to Avoid

• Do not use glucosamine or chondroitin sulfate, as guidelines conditionally recommend against their use 1
• Do not use intra-articular hyaluronic acid injections for hip osteoarthritis 1
• Do not delay appropriate surgical referral in patients with severe, refractory symptoms, as this prolongs unnecessary suffering 1
• Do not prescribe long-term opioids as routine management for hip osteoarthritis 1
• Do not assume conservative treatment will fail—44% of patients with hip disorders improve with conservative care alone 5
• Do not overlook the importance of patient education and self-management programs, which are conditionally recommended 1