What is the best course of action for a 60-year-old woman with impending right hip replacement surgery who is now experiencing significant left hip pain despite having adequate joint space?

Management of New Left Hip Pain in Patient Awaiting Right Hip Replacement

The left hip pain should be thoroughly evaluated with diagnostic imaging (MRI preferred) and a diagnostic intra-articular injection to determine if it represents true intra-articular pathology requiring surgical intervention versus extra-articular causes that can be managed conservatively, allowing the planned right hip replacement to proceed. 1

Immediate Diagnostic Approach

Rule Out Intra-Articular Pathology Despite Preserved Joint Space

• Obtain MRI of the left hip without delay to evaluate for labral tears, cartilage damage, synovitis, or early degenerative changes not visible on radiographs, as adequate joint space does not exclude significant intra-articular pathology 1, 2

• Consider diagnostic intra-articular injection with local anesthetic and corticosteroid under fluoroscopic or ultrasound guidance—complete pain relief confirms intra-articular source and provides therapeutic benefit if conservative management is chosen 1

• If the diagnostic injection fails to relieve pain, the diagnosis must be reconsidered and extra-articular sources systematically evaluated rather than attributing symptoms to early arthritis 3

Evaluate Extra-Articular Pain Generators

• Characterize the pain location precisely: lateral hip pain suggests trochanteric bursitis, deep buttock pain with sitting suggests ischiogluteal bursitis, and groin pain suggests intra-articular pathology 3, 4

• Use ultrasound or MRI to examine soft tissue structures including the greater trochanteric bursa, iliopsoas bursa, gluteal tendons, and surrounding musculature if extra-articular pathology is suspected 1, 3, 4

• The American College of Radiology recommends MRI or ultrasound specifically to evaluate extra-articular soft tissue abnormalities when the diagnosis remains unclear after radiographs 3

Treatment Algorithm Based on Findings

If Intra-Articular Pathology Confirmed

• Initiate conservative management immediately with oral NSAIDs (strong recommendation) when not contraindicated, as they are the first-line pharmacologic treatment for symptomatic hip osteoarthritis 1

• Consider physical therapy (moderate strength recommendation) for mild-to-moderate symptoms, which can provide relief and improve function 1

• Proceed with the planned right hip replacement as scheduled, since the right hip has end-stage disease requiring urgent intervention for quality of life 1

• Reassess left hip symptoms 3-6 months after right hip replacement, as many patients experience improvement in contralateral hip pain after unilateral replacement due to improved gait mechanics and reduced compensatory stress 5

If Extra-Articular Pathology Confirmed

• Treat trochanteric bursitis with targeted corticosteroid injection under imaging guidance if conservative measures (NSAIDs, activity modification) fail 3, 4

• For ischiogluteal bursitis, perform targeted injection of the ischiogluteal bursa under ultrasound or fluoroscopic guidance, as anatomical localization is critical for treatment success 3

• Proceed with right hip replacement without delay, as extra-articular left hip pathology should not postpone necessary surgery for end-stage right hip disease 1, 4

Critical Decision Points

Timing of Right Hip Surgery

• Do not delay the right hip replacement for conservative management of left hip pain unless the left hip demonstrates severe pathology requiring urgent bilateral intervention 1

• The right hip with end-stage disease and refractory symptoms takes priority for surgical intervention to restore function and quality of life 1

• Preoperative pain management for the left hip can be optimized with NSAIDs, acetaminophen, and potentially corticosteroid injection while proceeding with right hip surgery 1

When to Consider Bilateral or Staged Surgery

• If MRI reveals severe left hip pathology (advanced cartilage loss, large labral tear with mechanical symptoms) and diagnostic injection provides only temporary relief, discuss staged bilateral hip replacement with the patient 1

• Avoid oral opioids for chronic hip pain management, as consensus guidelines recommend against their use for symptomatic hip osteoarthritis 1

Common Pitfalls to Avoid

• Do not assume adequate joint space excludes significant hip pathology—labral tears, cartilage defects, and synovitis can cause severe pain with normal radiographic joint space 1, 2

• Do not attribute all hip region pain to the hip joint—extra-articular sources including bursitis, tendinopathy, and referred pain from the lumbar spine are common and require different management 3, 6, 4

• Do not perform blind injections without imaging guidance when clinical examination is equivocal, as incorrect anatomical targeting leads to treatment failure and diagnostic confusion 3

• Do not delay necessary right hip surgery for prolonged conservative management of left hip symptoms, as the right hip requires urgent intervention and left hip symptoms may improve after correcting right hip pathology 1, 5