Why Some Surgeons Recommend Hip Replacement Instead of Hip Preservation, Even for Younger Patients

Expert Perspective from Benedict Nwachukwu, MD, MBA — NYC Hip Preservation Surgeon

“Many of my patients come in thinking replacement is their only option, but after the right evaluation, we often find that hip preservation is both possible and the preferred course of treatment.”

If you’re a young, active adult and you’ve just been told you need a hip replacement, you may be surprised, or even scared. I see many patients in their 30s, 40s, and 50s seeking a second opinion after they’ve been told by another orthopedic surgeon that joint replacement is their only option. In many of these cases, hip preservation procedures such as arthroscopy, may still be a more effective treatment for them long term. They are often confused about why they were not informed of this option and the potential risks of having joint replacement surgery too young.

Here are some reasons why orthopedic surgeons might push for too-early hip replacement — and what you need to know to make an informed decision:

1. The Majority of Orthopedic Surgeons Focus on Joint Replacement

Whereas almost all orthopedic surgeons receive training in joint replacement, comparatively fewer commit to the specialized training necessary for performing hip preservation procedures. Labral repair, cam/pincer reshaping, and postless hip arthroscopy require fellowship-level training and substantial experience.

When a surgeon is not skilled in these newer methods, they will fall back on replacement surgery—even when preservation is still a viable or preferrable choice.

2. Hip Replacement Is Quicker and More Predictable than Hip Preservation

Technically, hip replacement surgeries are quicker, more straightforward, and easier to plan, than hip preservation surgeries. For some orthopedic surgeons, this makes joint replacement the go-to procedure for surgeons that are specially trained in preservation techniques.

In younger patients, however, premature joint replacement can lead to long-term issues, such as requiring future revision surgeries.

3. Imaging Alone Doesn’t Tell the Whole Story

Labral tears, mild cartilage damage, or bone impingements (FAI) may be seen on the X-ray or MRI but this does not always mean that the joint cannot be preserved. A non-preservation trained surgeon may overestimate the severity  they see in the films or presume that joint replacement is unavoidable.

To determine if hip joint preservation remains a viable option In my practice, I consider all of the following:

• Imaging
• A detailed physical exam
• patient history
• activity goals

4. Inadequate Equipment or Unavailability of Postless Technique

While most hospitals are equipped with OR traction tables that use a perennial post, not every hospital or surgical center is equipped with specialized traction tables needed for postless hip arthroscopy to reduce the associated with risks of perennial post including nerve compression, groin injury and perineal discomfort.

This specialized equipment and surgeons trained to use it are typically found at academic medical centers and high-volume hip preservation practices, like HSS. Without the appropriate table and equipment, a surgeon might not even offer arthroscopy as a treatment option even if you’re an otherwise perfect candidate.

5. Institutional or Practice Patterns

In some other cases, the hospital or practice culture is strongly based on joint replacement, due to referral patterns, reimbursement mechanisms, or historical clinical practice. In these situations, preservation may not even be contemplated.

Why I Do Things Differently

Hip preservation is all about getting function back and preserving your own joint.

Here’s how I approach treatment for younger, active patients:

• Preserve the joint when possible, especially for patients under 50 who want to maintain their current activity levels and sports performance
• Use minimally invasive, postless hip arthroscopy decreased risk and better outcomes.
• Delay hip replacement when appropriate, giving patients the opportunity to benefit from future innovations.
• Coordinate long-term rehabilitation and performance objectives, especially for athletes and highly active individuals.

This is particularly important in athletes and active patients, where joint mechanics, range of motion, and proprioception are more important than pain relief alone. Total hip replacement limits some athletic activity and places long-term limitations on high-impact activity.

Hip preservation surgery, however, treats the underlying structural issues—like labral tears or femoroacetabular impingement—while still preserving bone and cartilage. For athletes, this means a better chance at a return to high-level sports performance without the early limitations of a prosthetic joint.

Another key consideration is the effect of timing. Waiting even a decade to have a total hip replacement can leave the door open for future innovations. In the shoulder universe, for instance, more recent stemless implants have created much less complicated future revisions for younger patients.  Since hip replacement technology is advancing quickly, delaying a replacement by 5-10 years can significantly enhance your revision surgery options in the future.

It is important to be aware that while hip preservation is surgically less invasive—requiring less cutting and no joint or bone surface replacement—it generally requires more vigorous rehabilitation than a hip replacement. Physical therapy is needed to restore strength, flexibility, and joint control, particularly in those patients wishing to resume high-level activity. The recovery may take several months and demands a commitment to the PT.

Hip replacement, on the other hand, typically results in more rapid short-term recovery of pain and walking ability, and less formal rehabilitation is needed by some patients.  Younger, active patients have to be willing to trade permanent activity restrictions and long-term durability concerns for the benefit of a quicker recovery.

Considering Hip Replacement Surgery? Get a Second Opinion First

If you’re a younger athlete or active person who has been told you need a hip replacement, a second opinion from a fellowship-trained hip preservation specialist can help you explore additional hip preservation options.