What is the recommended treatment for degenerative joint disease of both hips with narrowed hip joints, acetabular sclerosis, and marginal spurs?

Treatment of Bilateral Hip Osteoarthritis with Advanced Degenerative Changes

For bilateral hip osteoarthritis with narrowed joint spaces, acetabular sclerosis, and marginal osteophytes, begin with a structured combination of non-pharmacological interventions (education, exercise, weight management if indicated, and assistive devices) alongside oral NSAIDs or acetaminophen, reserving total hip arthroplasty for patients with refractory pain and disability despite maximal conservative management. 1

Initial Conservative Management Approach

Non-Pharmacological Interventions (First-Line)

Start immediately with a comprehensive non-pharmacological program that includes: 1

• Patient education about the nature of osteoarthritis as a repair process, its causes, consequences, and prognosis, reinforced at each clinical encounter 1

• Individualized daily exercise regimen including:

  • Strengthening exercises (sustained isometric) for both legs, targeting quadriceps and proximal hip girdle muscles 1
  • Aerobic activity and exercise 1
  • Range of movement/stretching exercises 1
  • Exercise should follow "small amounts often" principle, linking to daily activities to become part of lifestyle 1

• Weight reduction if overweight or obese using structured strategies including regular self-monitoring, support meetings, increased physical activity, structured meal plans, and reduced fat/sugar intake 1

• Assistive devices and adaptations including:

  • Walking stick used on the contralateral side 1
  • Increasing height of chairs, beds, and toilet seats 1
  • Hand-rails for stairs 1
  • Appropriate and comfortable footwear 1

Pharmacological Management (Stepwise Approach)

Follow this algorithmic progression: 1

1. First-line oral analgesic: Acetaminophen (paracetamol) up to 4 g/day for mild-to-moderate pain due to its efficacy and safety profile 1

2. Second-line if inadequate response: NSAIDs at the lowest effective dose should be added or substituted 1

   • In patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agent, or selective COX-2 inhibitor 1

3. Third-line alternative: Opioid analgesics (with or without acetaminophen) are useful when NSAIDs are contraindicated, ineffective, or poorly tolerated 1

4. Adjunctive option: Intra-articular corticosteroid injections (guided by ultrasound or x-ray) may be considered for flares unresponsive to analgesics and NSAIDs 1

When Conservative Management Fails

Indications for Surgical Referral

Consider total hip arthroplasty when: 1

• Radiographic evidence of hip osteoarthritis is present (which you have: narrowed joint spaces, acetabular sclerosis, marginal osteophytes) 1
• AND refractory pain and disability persist despite maximal conservative therapy 1
• AND symptoms significantly impact quality of life and functional capacity 1

Special Surgical Considerations

• In young adults with symptomatic hip OA, especially with dysplasia or varus/valgus deformity, osteotomy and joint-preserving procedures should be considered before arthroplasty 1
• For bilateral disease, surgical planning should account for social determinants of health, as these may negatively affect length of stay, total cost of care, and mortality after THA 1

Critical Pitfalls to Avoid

• Do not skip conservative management: Even with advanced radiographic changes, a trial of structured conservative therapy is essential, as 44% of patients with symptomatic hip disorders improve with conservative care alone 2
• Do not use intra-articular hyaluronic acid injections: Strong evidence recommends against this intervention for symptomatic hip OA 1
• Do not assume radiographic severity predicts treatment response: Patients with end-stage radiographic changes may still respond to conservative measures 3, 2
• Do not delay physical therapy: Early structured PT can reduce pain and disability, potentially delaying surgical intervention 1, 3

Expected Outcomes and Timeline

• Conservative management should be trialed for at least 3 months before considering surgical options 2
• Patients who respond to conservative care demonstrate significant improvements in pain and function within this timeframe 2
• Post-THA, patients can expect pain-free ambulation without assistive devices when surgery is appropriately indicated 1
• Either formal PT or unsupervised home exercise is supported after THA 1