Case 1: Steroid Injection for Hip OA
Patient: 68-year-old with moderate hip OA (Tönnis grade 2), BMI 29, diabetic.
Presentation: Persistent groin pain, limited ROM, failed NSAIDs, and PT.
Intervention: Ultrasound-guided corticosteroid injection (triamcinolone 40 mg).
Outcome: Pain relief for 8 weeks; blood glucose spike for 48 hours managed with insulin adjustment.
Lesson: Steroid injections can provide short-term relief but require careful monitoring in diabetics and strict adherence to frequency limits (≤3/year, ≥12 weeks apart).
Case 2: PRP for Early Hip OA
Patient: 54-year-old recreational cyclist, mild OA (Tönnis grade 1).
Presentation: Hip stiffness and pain after activity; wants to avoid surgery.
Intervention: Single PRP injection under fluoroscopy; continued PT.
Outcome: VAS pain dropped from 5 to 2; functional improvement sustained for 9 months.
Lesson: PRP is a viable option for active patients with early OA seeking non-surgical relief.
Case 3: Transition to Hip Replacement
Patient: 72-year-old with severe OA (Tönnis grade 4), prior steroid and HA injections with diminishing benefit.
Presentation: Severe pain, mobility loss, difficulty with ADLs.
Intervention: Total hip arthroplasty.
Outcome: Post-op recovery over 4 months; pain-free ambulation at 6 months.
Lesson: THR remains the Gold standard for advanced OA when conservative measures fail.
Case 4: Insurance Market Impact on Hip Care
Patient: 65-year-old in wildfire-prone California region; multifamily property owner.
Presentation: Hip OA requiring PRP; elective THR planned in 12 months.
Complication: A spike in insurance premiums affects liquidity; the patient delays surgery and opts for PRP as an interim measure.
Lesson: External financial stressors can influence treatment sequencing—highlighting the need for flexible care plans.
Clinical Case Studies (Multi‑Clinic Vignettes)
Case A — Academic Sports Medicine Clinic (Hip Labral Tear → Arthroscopy)
Patient: 32-year-old female runner with mechanical groin pain, positive impingement signs; MRI confirms labral tear with cam morphology.
Intervention: Hip arthroscopy with cam correction and labral repair (tissue suitable for repair).
Outcome: mHHS improves from 62 pre‑op to 88 at 12 months; resumes recreational running with graded return.
Why this path: Systematic reviews show labral repair or reconstruction yields good‑to‑excellent outcomes, with mHHS typically improving into the 80–90 range at 1–10 years, and conversion to THA is driven mainly by age/OA severity rather than technique choice.
Lesson: In young patients with labral pathology and minimal OA, arthroscopy provides durable symptom relief when combined with correction of structural impingement.
Case B — PM&R Ultrasound‑Guided Clinic (Early Hip OA → PRP + PT)
Patient: 54-year-old cyclist, Tönnis 1 hip OA; wants to avoid surgery and steroids.
Intervention: Ultrasound-guided intra-articular PRP (leukocyte‑poor) + progressive abductor/core strengthening.
Outcome: VAS pain 5→2 by 6–12 months; improved iHOT‑12 and HOS‑ADL; maintains cycling.
Evidence basis: Pilot and RCT/meta-analytic data in hip OA show modest, often 6–12-month improvements in pain/Function with PRP versus HA or placebo, but criteria for choosing each remain unclear, highlighting the need for individualized assessment.
Technique note: Ultrasound guidance improves accuracy/safety for hip injections and is commonly used in office practice.
Case C — Community Orthopedics Clinic (Moderate Hip OA → HA Viscosupplementation)
Patient: 61-year-old male, Tönnis 2 OA, flares despite NSAIDs and PT; prefers to avoid steroids due to diabetes.
Intervention: Ultrasound-guided hyaluronic acid (high-density) injection.
Outcome: mHHS 60→82 at 12 months; fewer NSAID days per week; counseled that progression may still occur.
Evidence basis: Prospective and observational studies report functional/pain gains at 6–12 months in mild‑to‑moderate OA, with limited benefit in advanced OA; RCT/meta‑analyses suggest HA and PRP have comparable short-term pain outcomes, with modest effect sizes.
Lesson: HA can reduce symptoms in selected hip OA; set expectations that advanced OA (Tönnis 3) responds poorly and may require arthroplasty.
Case D — Pain Management & Sports Rehab Clinic (GTPS → PRP vs Steroid)
Patient: 60-year-old female with greater trochanteric pain syndrome (gluteus medius/minimus tendinopathy confirmed on US); prior PT with partial benefit.
Intervention: Single intratendinous PRP injection under ultrasound guidance; continued tendon‑loading rehab.
Outcome: mHHS and PASS improve at 12 weeks; benefit sustains at 2 years, whereas corticosteroid benefit (from previous episodes) peaked at 6 weeks and waned.
Evidence basis: RCTs show that PRP is superior to corticosteroids at 12 weeks and is sustained up to 2 years in chronic gluteal tendinopathy; CSI may help in the short term but is inferior to PRP in the long term.
Meta-perspective: Systematic reviews report mixed findings, but many suggest that PRP outperforms CSI beyond mid-term follow-up; CSI is not consistently superior to exercise or PRP.
Case E — VA Hospital / Primary Care–Orthopedics Collaboration (Hip OA with Diabetes → Steroid Use & Glycemia Plan)
Patient: 68-year-old veteran, Tönnis 2 OA with diabetes (HbA1c 8.1%); cannot tolerate NSAIDs; declines surgery now.
Intervention: Image-guided triamcinolone 40 mg injection with glucose monitoring protocol (days 1–3).
Outcome: Pain relief for ~8 weeks; day‑1 hyperglycemia (peaks ~280 mg/dL) managed with temporary adjustment; glucose returns to baseline by day 5.
Evidence basis: Intra-articular steroids can cause transient hyperglycemia—peaks within 24–72 h, occasionally higher and prolonged in poorly controlled diabetes; counsel and monitor accordingly.
Frequency rule: Limit steroids to ≤3–4 injections/year/hip, ≥12 weeks apart, especially in weight-bearing joints.
Case F — Arthroplasty Center (Advanced Hip OA → THR)
Patient: 72-year-old with end-stage OA (Tönnis 4), severe functional limitation; prior steroids/HA/PRP with limited durable relief.
Intervention: Total hip replacement (primary THA).
Outcome: Rapid pain resolution; independent ambulation by week 3; resumes golf at 4 months.
Evidence basis: THR is definitive for advanced OA, with >90% of patients achieving substantial pain relief and functional gains; however, potential long-term risks like revision surgery should be considered in shared decision-making.
Lesson: For severe OA or failure of non-operative care, THR offers the most durable solution; revision risk correlates with younger age and activity.
Case G — Academic Hip Preservation Clinic (Hip OA → PRP vs HA Pilot)
Patient: 55-year-old male, KL/Tönnis ~2–3 OA, internal rotation limited; desires biologic option before THA.
Intervention: Series of LP‑PRP injections; comparison cohort receives low‑molecular‑weight HA.
Outcome: At 6 months, the PRP group shows improvement in WOMAC and delayed conversion to THA compared with HA; IR at 90° flexion improves in PRP versus declines in HA.
Evidence basis: Double‑blind randomized pilot (University of Colorado) found PRP improved WOMAC and reduced THA conversions compared with HA over 24 months.
Context: Broader network meta-analyses show similar pain outcomes among PRP/HA/CSI/placebo at 2–6 months; differences can be minor and protocol‑dependent—set expectations.
Case H — Tertiary Sports Medicine Clinic (Alternative Hip Injection Approach)
Patient: 57-year-old with labral tear/FAI, difficult anterior window due to body habitus and pain; needs diagnostic/therapeutic intra-articular injection.
Intervention: Ultrasound-guided posterior approach hip injection, followed by fluoroscopic arthrogram confirmation.
Outcome: Accurate placement on first attempt in 9/10 cases; mild transient adverse events in 2/10; patient tolerates posterior approach well.
Evidence basis: Pilot data support the posterior US-guided approach as accurate and without serious adverse events, and it is useful when anterior access is challenging.