Treatment Recommendation for Advanced Hip Osteoarthritis with Femoral-Acetabular Dysplasia and CAM Lesion
This patient with advanced osteoarthritis and femoral-acetabular dysplasia should proceed directly to total hip arthroplasty (THA) without delay for additional nonoperative treatments, as the imaging demonstrates end-stage degenerative changes that are beyond the scope of joint-preserving procedures. 1
Rationale for Total Hip Arthroplasty
The imaging findings demonstrate advanced osteoarthritis with:
- Productive changes of the femoral head
- Circumferential anterior-superior acetabular cartilage degeneration
- Underlying structural abnormalities (CAM lesion and dysplasia)
For patients with advanced hip arthritis, the American College of Rheumatology strongly recommends treatment with total hip arthroplasty, which provides improvements in pain, functioning, and hip range of motion. 1 The 2023 ACR/AAHKS guidelines specifically address this clinical scenario, conditionally recommending against delaying THA to pursue additional nonoperative treatments including physical therapy, NSAIDs, ambulatory aids, or intra-articular injections in patients with moderate-to-severe symptomatic OA for whom nonoperative therapy has been ineffective. 1
Why Joint-Preserving Surgery Is Not Appropriate
While hip arthroscopy with labral repair and treatment of FAI (femoroacetabular impingement) can be considered for younger patients with early chondral damage, this patient has progressed beyond that threshold. 1
Joint-preserving options like microfracture are indicated only for focal, contained lesions measuring <4 cm² in patients with minimal osteoarthritis (Tönnis grade ≤1). 1, 2 This patient has:
- Advanced osteoarthritis (not minimal)
- Circumferential acetabular cartilage degeneration (not focal)
- Productive bony changes indicating end-stage disease
Similarly, periacetabular osteotomy (PAO) for dysplasia is only appropriate in patients with preserved radiographic joint space and earlier disease stages. 3 This patient's advanced degenerative changes make PAO contraindicated.
Addressing the Potential Labral Tear
The radiologist notes they "cannot exclude acute labral tear" in the setting of anterior-superior acetabular cartilage degeneration. In the context of advanced osteoarthritis, labral pathology is secondary to the underlying degenerative process and does not change the treatment algorithm. 4, 5
- Labral tears in advanced OA are degenerative rather than traumatic 5, 6
- Isolated labral repair without addressing the underlying structural pathology (dysplasia, CAM lesion) leads to poor outcomes 3
- With circumferential cartilage loss, the labrum cannot be meaningfully preserved or repaired 1
Pre-Surgical Optimization
Before proceeding to THA, address modifiable risk factors:
Conditionally recommend delaying surgery for:
- Nicotine cessation or reduction if the patient uses tobacco products 1
- Improved glycemic control if the patient has diabetes mellitus (though no specific HbA1c threshold is mandated) 1
Do NOT delay surgery for:
- Additional physical therapy, NSAIDs, or intra-articular injections 1
- Rigid BMI cutoffs (though counsel on increased surgical risks with obesity) 1
- The presence of severe deformity or bone loss (the dysplasia and CAM lesion) 1
Surgical Considerations
The surgery should be performed by orthopedic surgeons and at hospitals highly experienced in joint replacement, particularly given the underlying dysplastic anatomy. 1 The structural abnormalities (dysplasia, CAM lesion) may require:
- Specialized implant selection
- Potential use of modular components
- Careful attention to hip biomechanics and offset restoration
Common Pitfalls to Avoid
Do not pursue arthroscopic labral repair or FAI correction in the setting of advanced OA - This delays definitive treatment and subjects the patient to an ineffective procedure 1, 7
Do not mandate prolonged conservative treatment - The 2023 guidelines specifically address that 91% of patients deemed appropriate for TKA had their surgery delayed, leading to further pain and disability 1
Do not delay for rigid preoperative criteria unless addressing nicotine use or glycemic control - Coverage determination policies often cite literature that doesn't apply to patients with advanced disease who are already indicated for THA 1
Do not overlook the structural abnormalities - The dysplasia and CAM lesion require surgical expertise and may affect implant positioning and long-term outcomes 3
Patient Education and Shared Decision-Making
The decision to proceed with THA should involve shared decision-making, discussing the patient's unique risks and benefits. 1 Key discussion points include: