Yes, refer this patient to orthopedics for evaluation and management of bilateral hip pathology
Given the combination of moderate degenerative joint disease and cam-type femoroacetabular impingement (FAI) morphology on radiographs, orthopedic referral is warranted to determine if the patient is a candidate for joint-preserving surgery or requires planning for eventual arthroplasty.
Clinical Reasoning
The presence of both moderate DJD and cam-type FAI morphology creates a critical decision point that requires orthopedic expertise:
Why Referral is Indicated
Cam morphology is a causal risk factor for progressive hip osteoarthritis 1. The convex prominence at the femoral head-neck junction generates abnormal contact stresses during hip motion, leading to progressive labral and chondral damage 2. This patient already has moderate DJD, suggesting the degenerative process is underway.
The key question an orthopedic surgeon must answer is: Is there sufficient preserved cartilage to benefit from cam resection, or has the joint degenerated beyond the point where joint-preserving surgery would be beneficial?
Timing Matters for Outcomes
Evidence shows that age ≥55 years and preoperative Tönnis stage II (moderate OA) are independent risk factors for conversion to total hip arthroplasty after cam resection 3. In that study, 23% of hips required THA at mean 22 months follow-up, with 5-year hip preservation survival of only 74.9%. However, patients who were younger with less advanced disease had significantly better outcomes.
This means the window for successful joint preservation may be closing, making timely orthopedic evaluation critical.
What the Orthopedic Evaluation Will Determine
The orthopedic surgeon will assess:
- Symptom severity and functional limitation - Is the patient having activity-related groin pain, clicking, catching, or limited range of motion? 2
- Physical examination findings - Specifically flexion-adduction-internal rotation (FADIR) and flexion-abduction-external rotation (FABER) tests 2
- Advanced imaging - MRI or MR arthrogram to evaluate cartilage integrity, labral pathology, and degree of chondral loss 4, 2
- Degree of arthritis - Tönnis grading on radiographs to determine if joint preservation is feasible 3
Treatment Pathways
If cartilage is relatively preserved: Hip arthroscopy with cam resection and labral repair may improve symptoms and potentially slow progression 2, 5
If moderate-to-advanced arthritis is present: The patient may be better served by conservative management (NSAIDs, PT, intra-articular corticosteroid injections) 6 while planning for eventual total hip arthroplasty when symptoms warrant
If end-stage arthritis: Direct pathway to THA discussion 6
Bilateral Disease Consideration
The bilateral nature of this pathology is significant. Even if one hip is too degenerated for joint preservation, the contralateral hip might benefit from earlier intervention. Cam morphology on the asymptomatic side can progress to symptomatic FAI syndrome and OA 7, 1, so bilateral evaluation is prudent.
Common Pitfall to Avoid
Do not delay referral waiting for conservative measures to fail if the patient is symptomatic. Unlike isolated mild hip OA where conservative management is first-line 6, the combination of structural cam deformity with existing moderate DJD requires surgical expertise to determine the optimal treatment window. Early identification of FAI syndrome enables timely intervention and offers potential to modify disease trajectory 1.
The orthopedic surgeon can always recommend conservative management if appropriate, but the structural assessment and surgical planning expertise is essential for this patient's long-term hip preservation and quality of life.