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

Treatment Approach for Moderate to Severe Hip Osteoarthritis with Labral Degeneration

This 68-year-old patient with moderate to severe hip osteoarthritis, diffuse labral degeneration, and subacute osteochondral injury should proceed directly to total hip arthroplasty (THA) evaluation without mandatory delays for additional conservative treatments, as further nonoperative management is unlikely to provide meaningful benefit and may worsen pain, function, and quality of life. 1

Immediate Surgical Referral Pathway

Primary Recommendation: Total Hip Arthroplasty

• Proceed to THA consultation without delay for patients with moderate to severe radiographic hip osteoarthritis who have completed trials of appropriate nonoperative therapy and continue to experience functionally limiting pain. 1
• The American College of Rheumatology and American Association of Hip and Knee Surgeons conditionally recommend against delaying THA for additional trials of physical therapy, NSAIDs, braces/ambulatory aids, or intra-articular injections in patients already indicated for surgery. 1
• Delaying surgery in patients with moderate to severe disease may cause increased pain, progressive loss of function, and worsening of medical comorbidities due to limited mobility. 1

Why Conservative Management Should Not Delay Surgery

• Physical therapy: While PT may benefit mild-to-moderate hip OA, mandated physical therapy should not delay THA in patients already indicated for surgery, as the severity of disease limits benefit and may increase pain. 1
• NSAIDs: Oral NSAIDs are associated with adverse events (peptic ulcer disease, acute kidney injury, cardiovascular risk, bleeding) with limited clinical benefit in severe disease. 1
• Intra-articular corticosteroid injections: Should not delay THA, though may be considered for acute flares while awaiting surgery (noting increased infection risk if surgery performed within 3 months of injection). 1
• Hyaluronic acid injections: Should not be used for hip OA due to insufficient evidence. 1, 2

Bridging Management While Awaiting Surgery

Acceptable Short-Term Interventions (If Surgery Delayed for Personal/Medical Reasons)

• Oral NSAIDs at lowest effective dose when not contraindicated, with gastroprotective agents for patients at increased GI risk. 1, 2
• Acetaminophen up to 4g/day may be considered for symptomatic relief, though efficacy is limited in severe disease. 1, 2
• Assistive devices (cane, walker) to reduce joint load and improve mobility. 2
• Opioid analgesics may be useful alternatives when NSAIDs are contraindicated, ineffective, or poorly tolerated, though should be limited due to side effects. 2

Preoperative Optimization Requirements

• Delay surgery only for poorly controlled diabetes mellitus to improve glycemic control (conditional recommendation). 1
• Delay surgery for nicotine use reduction/cessation in patients with nicotine dependence (conditional recommendation with low-quality evidence). 1
• Do not delay surgery for weight reduction in patients with BMI 35-50+ unless other compelling medical reasons exist. 1

Critical Pitfalls to Avoid

Insurance/Coverage Barriers

• Coverage determination policies often mandate additional nonoperative treatments that are not evidence-based for patients already indicated for THA. 1
• Less than 10% of literature cited in major commercial payers' coverage policies addresses effectiveness of nonoperative treatments in patients with moderate-to-severe OA already indicated for THA. 1
• Only 9% of patients deemed appropriate for THA undergo timely surgery (within 2 years), with delays leading to further pain, functional limitations, and increased disability risk. 1

Labral and Osteochondral Pathology Considerations

• The diffuse labral degeneration and subacute osteochondral injury in this patient are secondary to the severe osteoarthritis and will not improve with conservative management. 3
• Arthroscopic treatment of labral tears is appropriate for younger patients with mechanical symptoms and minimal arthritis, but outcomes are directly dependent on the extent of chondral lesions—severe chondral damage (as in this case) predicts poor arthroscopic outcomes. 3
• The mild focal femoral head cortical depression with adjacent edema represents a subacute injury that will not heal with conservative measures in the setting of severe arthritis. 3

Patient-Centered Decision Making

• Preoperative education should be delivered using written materials and coordination with support systems. 1
• Social determinants of health may negatively affect length of stay, total cost of care, and mortality after THA and should be addressed in surgical planning. 1
• Patients overwhelmingly prefer to proceed directly with surgical treatment rather than delay for mandatory conservative therapies (93% in one survey). 1
• Either formal PT or unsupervised home exercise is supported after THA—formal PT is not mandatory postoperatively. 1