Why is an arthroscopic procedure not recommended for an older patient with hip osteoarthritis (OA)?

Why Arthroscopic Procedures Are Not Recommended for Older Patients with Hip Osteoarthritis

Arthroscopic procedures should not be performed in older patients with established hip osteoarthritis because they cannot reverse cartilage damage, have high conversion rates to total hip arthroplasty (often within one year), and lack evidence for meaningful clinical benefit in this population. 1, 2, 3

The Fundamental Problem: Arthroscopy Cannot Reverse Hip OA

• Hip osteoarthritis is irreversible—current treatments can only control symptoms and improve function, not restore damaged cartilage 4, 1
• Arthroscopic debridement and joint-preserving procedures only redistribute mechanical forces; they do not reverse existing structural damage 1, 5
• The American College of Rheumatology explicitly states that no current intervention, including surgical debridement, provides structural restoration of hip cartilage 4, 1

Poor Outcomes and High Conversion Rates in Older Adults

• In Medicare patients (≥65 years), 18.5% require conversion to total hip arthroplasty within 2 years of hip arthroscopy 3
• Two-thirds of all revision procedures occur within one year of the primary arthroscopy 2
• Patients with a pre-existing diagnosis of hip osteoarthritis have 5.3 times higher odds of requiring reoperation after arthroscopy 2
• The conversion rate to THA ranges from 9.5% to 50% across studies, with increasingly worse outcomes as OA severity increases 6

Evidence Quality and Clinical Reality

• Despite a 280% increase in hip arthroscopy utilization in Medicare patients from 2005-2014, the clinical evidence remains inconclusive and of low quality 3, 6
• Hip arthroscopy represents only 0.3% of procedures compared to THA utilization in this age group, reflecting appropriate clinical judgment 2
• The American College of Rheumatology guidelines from 1995 stated that arthroscopic debridement "cannot be routinely recommended" for knee OA due to insufficient evidence—this principle applies equally to hip OA 7

When Hip Arthroscopy May Have Limited Role

• Early hip arthritis only (not established OA): Hip preservation surgery may delay progression in carefully selected younger patients with pre-arthritic abnormalities like femoroacetabular impingement 8
• No role whatsoever in end-stage arthritis 8
• Patients aged 65-74 years with pre-existing OA diagnosis should have arthroscopy approached with extreme caution given high conversion rates 3

The Appropriate Treatment Algorithm

For older patients with symptomatic hip OA:

1. Conservative management first: NSAIDs, physical therapy, weight management, assistive devices 4, 1
2. Total hip replacement when conservative measures fail: This is the definitive treatment with 43-84% pain-free outcomes at 9.4 years follow-up 4, 1
3. Use cemented femoral stems in older patients undergoing THA to reduce periprosthetic fracture risk (strong recommendation) 9, 4

Critical Pitfall to Avoid

Do not offer arthroscopy to older patients with established hip OA based on the false premise that it will "buy time" before arthroplasty. The evidence shows that most patients who fail arthroscopy require THA within one year anyway, subjecting them to two procedures instead of one, with additional costs, recovery time, and surgical risks 2, 3, 6