What is the recommended management approach for a patient with moderate to severe left hip joint arthrosis, diffuse labral degeneration, and suspected subacute osteochondral injury?

Management of Moderate-to-Severe Hip Arthrosis with Labral Degeneration and Subacute Osteochondral Injury

For this patient with moderate-to-severe hip arthrosis, diffuse labral degeneration, and a subacute osteochondral injury, total hip arthroplasty (THA) is the definitive treatment, and should proceed without delay for additional nonoperative therapies given the severity of disease. 1

Primary Treatment Recommendation

The 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons conditionally recommend proceeding directly to THA without delaying for trials of physical therapy, NSAIDs, ambulatory aids, or intraarticular injections in patients with moderate-to-severe symptomatic osteoarthritis for whom nonoperative therapy has been ineffective. 1

• The moderate-to-severe arthrosis with cartilage loss, joint space narrowing, osteophytosis, and subchondral bone marrow edema on MRI indicates advanced disease that is beyond the scope of joint-preserving interventions 1
• The reactive joint effusion and diffuse labral degeneration further confirm that this hip has progressed beyond salvageable pathology 1

Why Joint-Preserving Surgery is NOT Appropriate

Joint-preserving surgical options (microfracture, osteochondral grafting, labral repair) are contraindicated in this patient due to the presence of moderate-to-severe osteoarthritis. 1

The American Academy of Orthopaedic Surgeons algorithms for joint-preserving surgery require ALL of the following criteria, which this patient does NOT meet: 1

• Age from skeletal maturity to 50 years
• Minimal (Tönnis grade ≤1) or no sign of osteoarthritis on radiography - this patient has moderate-to-severe arthrosis
• No inflammatory arthritis
• One or more full-thickness defects, but no bipolar lesions
• A well-contained lesion
• Ability to perform rigorous postoperative physical therapy

The presence of diffuse labral degeneration (not an isolated tear), cartilage loss, joint space narrowing, and osteophytosis definitively excludes this patient from joint-preserving approaches 1

Management of the Subacute Osteochondral Injury

The 3mm focal depression of the superior femoral head with adjacent subcutaneous edema does not change the treatment plan, as it exists in the context of advanced arthrosis. 1

• Isolated osteochondral injuries can be treated with mosaicplasty or osteochondral allograft in young patients (<45-50 years) with focal lesions <3 cm² and minimal osteoarthritis 1, 2
• However, when moderate-to-severe osteoarthritis is present, these techniques fail because the surrounding joint surface is already compromised 1
• The subacute nature (not acute traumatic) and presence of advanced arthrosis make this a component of the overall degenerative process rather than an isolated treatable lesion 1

Preoperative Optimization

Before proceeding to THA, address modifiable risk factors: 1

• Glycemic control: If diabetic, conditionally recommend delaying THA to improve glycemic control (no specific HbA1c threshold specified, but the 2023 guidelines emphasize optimization) 1
• Nicotine cessation: Conditionally recommend delaying THA for nicotine reduction or cessation 1
• Weight optimization: Do NOT delay surgery to meet rigid BMI thresholds, but counsel on increased surgical risks and encourage weight loss 1
• Social determinants: Plan surgical timing to ensure adequate postoperative support, as this affects length of stay and outcomes 1

Common Pitfalls to Avoid

Do not delay THA for additional trials of conservative management in this patient with moderate-to-severe disease. 1

• Mandated physical therapy to delay or avoid surgery is not recommended when THA is indicated 1
• Delaying surgery for physical therapy, NSAIDs, braces, or intraarticular injections may cause increased pain and functional decline due to disease severity 1
• The 2023 guidelines specifically state that in patients indicated for THA through shared decision-making who have completed trials of appropriate nonoperative therapy, proceeding without delay is conditionally recommended 1

Do not attempt arthroscopic labral repair or osteochondroplasty in the setting of moderate-to-severe osteoarthritis. 1, 3

• These procedures are designed for younger patients with mechanical symptoms from femoroacetabular impingement and minimal arthritic changes 3
• The diffuse labral degeneration (not an isolated tear) and advanced cartilage loss predict poor outcomes from arthroscopic intervention 1