What is the recommended treatment for a patient with moderate to advanced degenerative changes of the hips, right greater than left, with intact pelvis and mild degenerative changes of the SI joints and pubic symphysis?

Treatment of Moderate to Advanced Hip Osteoarthritis

For moderate to advanced degenerative hip changes, initiate a combined non-pharmacological and pharmacological approach starting with acetaminophen up to 4g daily, exercise therapy, weight reduction if overweight, and assistive devices, escalating to NSAIDs if inadequate response, with total hip arthroplasty reserved for refractory pain and disability despite maximal medical management. 1

Initial Conservative Management

Non-Pharmacological Interventions (Start Immediately)

• Implement regular patient education about the disease process and self-management strategies 1
• Prescribe structured exercise programs focusing on hip range of motion, strengthening, and aerobic conditioning, which reduces pain and disability 1, 2
• Recommend weight reduction if BMI is elevated, as obesity is a modifiable risk factor that increases adverse events and lowers patient-reported outcomes 1
• Provide assistive devices including a walking stick and appropriate insoles to reduce mechanical stress on the affected hip 1

Pharmacological Pain Management Algorithm

First-line therapy:

• Start acetaminophen (paracetamol) up to 4g daily for mild-moderate pain due to its efficacy and safety profile as the preferred long-term oral analgesic 1, 2

Second-line therapy (if acetaminophen inadequate):

• Add or substitute NSAIDs at the lowest effective dose for patients responding inadequately to acetaminophen 1, 2
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agents, or selective COX-2 inhibitors (coxibs) 1, 3

Third-line therapy:

• Consider opioid analgesics with or without acetaminophen as alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated 1
• Note that patients should be weaned off chronic opioid therapy before considering surgical intervention, as narcotic use increases perioperative adverse events 1

Adjunctive Pharmacological Options

• Symptomatic slow-acting drugs for osteoarthritis (SYSADOA) including glucosamine sulfate and chondroitin sulfate in combination may be considered for moderate to severe osteoarthritis, though effect sizes are small 1, 2, 3
• Intra-articular corticosteroid injections (ultrasound or x-ray guided) may be considered for acute flares unresponsive to analgesics and NSAIDs 1

Treatment Individualization Based on Risk Factors

Tailor treatment intensity according to: 1

• Hip-specific risk factors: obesity, adverse mechanical factors, physical activity level, presence of dysplasia
• General risk factors: age, sex, comorbidities (especially diabetes), concurrent medications
• Pain intensity, degree of disability, and functional handicap
• Radiographic severity and location of structural damage
• Patient expectations and preferences

Surgical Intervention Criteria

When to Consider Total Hip Arthroplasty

Total hip replacement must be considered when patients have radiographic evidence of hip OA with refractory pain and disability despite maximal conservative management 1

The evidence shows 43-84% of patients achieve pain-free outcomes at 9.4-year follow-up, with acceptable revision rates of 0.18-2.04 per 100 person-years 1, 4

Preoperative Optimization Requirements

Before proceeding with surgery, patients must optimize: 1

• BMI reduction (elevated BMI increases adverse events and lowers patient-reported outcomes)
• Glycemic control (HbA1c optimization for diabetic patients, as poorly controlled diabetes increases perioperative complications)
• Smoking cessation (tobacco use increases adverse events after THA)
• Opioid weaning under physician guidance

Joint-Preserving Surgery Considerations

• Osteotomy and joint-preserving procedures should be considered only in young adults with symptomatic hip OA, especially with dysplasia or varus/valgus deformity 1
• These procedures are NOT appropriate for moderate to advanced degenerative changes, as they only redistribute mechanical forces without reversing existing cartilage damage 4

Critical Clinical Pitfalls to Avoid

Do not delay appropriate surgical referral when conservative measures fail, as prolonged disability significantly impacts quality of life and functional independence 1

Do not use intra-articular hyaluronic acid for hip OA, as there is no RCT evidence supporting its use in the hip (unlike knee OA) 1

Recognize that current treatments cannot reverse hip osteoarthritis or restore damaged cartilage—they only control symptoms 4

The mild degenerative changes of the SI joints and pubic symphysis noted on imaging are likely incidental findings and should not distract from addressing the primary pathology of moderate to advanced hip OA, which is the main source of symptoms and disability.