From the Guidelines
For a patient with severe osteoarthritis of the left hip and evidence of osteonecrosis, total hip arthroplasty (hip replacement surgery) is the recommended definitive treatment, as it directly addresses both conditions and can significantly improve morbidity, mortality, and quality of life. The decision to proceed with surgery should be made through a shared decision-making process between the physician and patient, considering the unique risks and benefits for the individual patient 1.
Pre-Surgical Management
Before surgery, pain management is crucial and may include medications such as acetaminophen and NSAIDs. According to the guideline, for patients with moderate-to-severe symptomatic OA or advanced symptomatic ON with secondary arthritis, proceeding directly to surgery without delay for additional nonoperative treatment of the joint problem is conditionally recommended 1. However, managing comorbidities such as obesity and diabetes mellitus is important. For patients with obesity, surgery should not be delayed to meet a rigid weight or body mass index threshold, but patients should be educated on the increased risk of medical and surgical complications due to their obesity 1. For patients with diabetes mellitus, delaying surgery to allow for improved glycemic control is conditionally recommended 1.
Surgical Intervention
The presence of osteonecrosis complicates the condition, potentially leading to rapid joint deterioration and collapse, making surgical intervention more urgent. Total hip arthroplasty can address both the degenerative changes from osteoarthritis and the compromised blood supply to the femoral head characteristic of osteonecrosis.
Post-Surgical Rehabilitation
Post-surgery rehabilitation is crucial and typically involves early mobilization, progressive weight-bearing exercises, and strengthening protocols over 2-3 months. This comprehensive approach is aimed at improving the patient's quality of life, reducing morbidity, and minimizing the risk of mortality associated with prolonged immobilization and surgical complications.
Considerations
It's also important to consider the patient's lifestyle and habits, such as nicotine use, which may impact surgical outcomes. Delaying TJA to achieve nicotine cessation or decreased use of nicotine products is conditionally recommended 1. By addressing these factors and proceeding with total hip arthroplasty when appropriate, patients with severe osteoarthritis and osteonecrosis can experience significant improvements in their quality of life and reduction in pain and disability.
From the Research
Severe Osteoarthritis of the Left Hip with Osteonecrosis
- The patient's condition involves severe osteoarthritis of the left hip with evidence of osteonecrosis, which is a devastating disease that can lead to significant pain and disability 2.
- Osteonecrosis of the femoral head is a common indication for total hip arthroplasty (THA), which can provide significant pain relief and improvement in function 2, 3.
Treatment Recommendations
- Total hip arthroplasty (THA) is a viable treatment option for patients with severe osteoarthritis and osteonecrosis of the femoral head, with recent studies showing excellent results with second- and third-generation designs that incorporate advances in bearing technology 2.
- The German Consensus Initiative recommends that patients with hip osteoarthritis who are considering THA should meet certain criteria, including a confirmed diagnosis of hip OA, present and documented individual burden of illness, ineffectiveness of non-surgical therapies, and absence of any contraindications 3.
- Pharmaceutical treatment options, such as oral and topical nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular corticosteroids, and hyaluronic acid injections, may be considered for patients with osteoarthritis, but their use should be carefully evaluated based on the latest evidence and recommendations 4.
Considerations for Patients with Osteonecrosis
- Patients with osteonecrosis of the femoral head may be at increased risk of surgical and medical complications after THA, including mechanical complications, dislocation, and pulmonary embolism 5.
- Patients with sickle cell disease who undergo THA for osteonecrosis of the hip are at increased risk of medical and surgical complications, including pain crises, acute chest syndrome, and cardiac complications 6.
- Surgeons should be aware of the unique challenges in patients with osteonecrosis and take steps to minimize the risk of complications and optimize outcomes 2, 5, 6.