For a young patient with about 4 years of early‑onset hip osteoarthritis, persistent stiffness, and intra‑articular chondromatous loose bodies with diseased synovium, which surgical procedure should be chosen first?

Hip Arthroscopy with Loose Body Removal and Synovectomy

For this young patient with early-onset hip osteoarthritis, intra-articular chondromatous loose bodies, and diseased synovium, hip arthroscopy with removal of loose bodies and synovectomy should be the first surgical procedure. 1, 2, 3

Rationale for Arthroscopic Approach

Hip arthroscopy is the preferred initial surgical intervention because it allows complete removal of loose bodies, synovectomy of diseased tissue, and assessment of chondral damage while preserving the joint in this young patient. 2, 3

Key Advantages in This Clinical Scenario

• Arthroscopic treatment enables direct visualization and removal of multiple loose bodies throughout the joint compartments, including difficult-to-access areas like the posteromedial pouch. 3

• Complete synovectomy of the diseased synovium can be performed arthroscopically to address the underlying pathology and reduce recurrence risk. 2, 3

• Patients typically achieve weight-bearing ambulation within 2 days and hospital discharge within 3-5 days post-operatively. 3

• The minimally invasive nature results in less surgical trauma, better post-operative rehabilitation, and faster return to activities of daily living compared to open approaches. 1, 4

Technical Considerations

• Standard anterior, anterolateral, and posterolateral portals should be utilized, with consideration of an additional medial portal for accessing the posteromedial pouch where loose bodies commonly accumulate. 3

• Extensive capsulectomy should be performed during the arthroscopic procedure without capsular repair—this allows any remaining loose bodies to migrate out of the extracapsular space and spontaneously resorb. 5

• In cases where extensive capsulectomy is performed, approximately 71% of remaining loose bodies will disappear at follow-up without requiring additional intervention. 5

Management of Associated Chondral Lesions

Since this patient has 4 years of early osteoarthritis, chondral damage assessment and treatment must be addressed during the same arthroscopic procedure:

• For chondral defects <2 cm², microfracture should be performed as first-line treatment, achieving approximately 93% defect fill with good-quality fibrocartilage. 6, 7

• For defects 2-6 cm² in size, osteochondral allograft transplantation becomes the preferred option, providing immediate hyaline cartilage replacement with superior mechanical properties. 6, 7

• Delaminated cartilage that appears macroscopically healthy can be salvaged with suture repair or fibrin adhesive rather than resection. 6, 7

Expected Outcomes

• Harris Hip Score typically improves from approximately 39 pre-operatively to 82 post-operatively, with 75% of patients achieving good or excellent outcomes. 3

• Visual analog pain scores decrease from 8.1 to 3.1 on average following arthroscopic treatment. 3

• Range of motion improves post-operatively in the majority of patients. 3

Critical Pitfalls to Avoid

• Do not perform open arthrotomy with hip dislocation as the initial procedure in this young patient—this approach carries higher morbidity, longer recovery, and should be reserved for cases where arthroscopy fails or is technically impossible. 1, 2

• Incomplete synovectomy increases recurrence risk (16.7% in published series), so thorough removal of all diseased synovium is essential. 3

• The posterolateral and posteromedial peripheral compartments are technically challenging to access arthroscopically—failure to adequately address these areas may leave residual loose bodies. 3

• Progression to osteoarthritis occurs in approximately 17% of cases despite successful loose body removal, so patients must be counseled that this procedure delays but may not prevent eventual joint replacement. 3

Post-operative Management

• Immediate weight-bearing as tolerated is typically permitted within 2 days. 3

• Structured rehabilitation focusing on hip range of motion and strengthening should begin early. 8

• Radiographic surveillance is necessary to monitor for disease recurrence and osteoarthritis progression. 3, 5

When to Consider Alternative Approaches

• If chondral lesions exceed 6-8 cm² or if Tönnis grade 3 osteoarthritis is present, total hip arthroplasty becomes more appropriate than joint preservation. 6, 7

• Recurrent disease after arthroscopic treatment (occurring in approximately 17% of cases) may require repeat arthroscopy or conversion to open procedures. 3