What treatment options are available for a young patient with impaired mobility, who has tried conservative therapies without success, and needs to improve mobility to facilitate weight loss, with the goal of prolonging the need for Total Hip Arthroplasty (THA)?

Treatment Recommendation for Young Patient with Hip Pathology

For this young patient who has failed conservative therapies and requires improved mobility to facilitate weight loss while delaying THA, joint-preserving surgical interventions—specifically intra-articular injections or arthroscopic procedures such as microfracture—represent the most appropriate next step, provided the patient meets specific criteria including minimal osteoarthritis (Tönnis grade ≤1) and well-contained chondral lesions. 1

Clinical Decision Algorithm

Step 1: Confirm Eligibility for Joint-Preserving Surgery

The patient must meet ALL of the following criteria to proceed with joint-preserving interventions 1:

• Age: Skeletal maturity to 50 years 1
• Radiographic findings: Minimal (Tönnis grade ≤1) or no osteoarthritis 1
• Lesion characteristics: Well-contained, unipolar (not bipolar) full-thickness defects 1
• No inflammatory arthritis 1
• Functional capacity: Ability to perform rigorous postoperative physical therapy 1

Step 2: Lesion Size-Based Treatment Selection

For femoral head lesions 1:

• <2 cm: First-line = Microfracture; Second-line = Mosaicplasty or osteochondral allograft 1
• 2-6 cm: First-line = Osteochondral allograft; Second-line = Osteochondral transplantation or microfracture 1
• 6-8 cm: Osteochondral allograft transplantation (single plug) 1
• >8 cm: Consider THA 1

For acetabular lesions 1:

• <2 cm: Microfracture 1
• 2-6 cm: Microfracture or suture repair (if delaminated chondral flap with viable cartilage) 1
• >6 cm: Consider conversion to THA 1

Step 3: Address Weight Loss Paradox

Do NOT delay necessary surgical intervention for weight reduction. The 2023 ACR/AAHKS guidelines explicitly recommend proceeding with THA without delaying for weight reduction across all BMI categories (≥50,40-49,35-39), as rigid BMI thresholds are discouraged 1. This principle extends to joint-preserving procedures, as:

• Pain and immobility from hip pathology actively prevent weight loss 1
• Improved mobility from surgical intervention facilitates weight reduction 1
• Delaying surgery may worsen medical comorbidities due to limited mobility 1

Step 4: Timing Considerations

Proceed without arbitrary delays 1:

• No mandated 3-month waiting period 1
• No requirement for additional physical therapy trials if already failed 1
• No requirement for additional injection trials if already failed 1

The patient has already completed trials of conservative therapies without success, meeting the threshold for surgical consideration 1.

Critical Caveats and Pitfalls

When Joint-Preserving Surgery is NOT Appropriate

Proceed directly to THA if 1:

• Radiographic evidence shows moderate-to-severe osteoarthritis (Tönnis grade >1) 1
• Bipolar lesions (both femoral and acetabular involvement) 1
• Refractory pain or disability with structural damage 1
• Age >50 years (relative contraindication) 1

Modifiable Risk Factors to Address

While surgery should not be delayed for weight loss, DO delay for 1:

• Poorly controlled diabetes: Improve glycemic control (no specific HbA1c threshold mandated, but optimization recommended) 1
• Active nicotine use: Counsel for reduction/cessation, though complete cessation is not required before proceeding 1

Evidence Quality Limitations

The literature supporting joint-preserving hip procedures consists primarily of small case series without control groups and lacks long-term follow-up data 1. However, in appropriately selected young patients, these interventions represent the only option to delay THA and improve mobility necessary for weight loss.

Postoperative Requirements

Protected weight-bearing is mandatory following joint-preserving procedures to prevent fracture and optimize healing 2. Regular radiographic surveillance is essential to monitor for disease progression or femoral head collapse 2.

Shared Decision-Making Framework

Educate the patient that 1:

• Joint-preserving surgery may provide 5-10 years of symptom relief before THA becomes necessary
• Improved mobility from surgery will facilitate weight loss more effectively than delaying surgery
• Surgical risks exist but are acceptable in properly selected candidates
• If joint-preserving criteria are not met, proceeding directly to THA is appropriate and should not be delayed for weight reduction