Surgery for osteoarthritis, even without pain?

My doctor took an x-ray of my hip and told me that I have severe arthritis. He said I need surgery, but my hip doesn't hurt that much.  Do I need surgery? 

            One of the first things I tell medical students and residents whenever I am teaching them about osteoarthritis is that we treat people, not films.  The fact is that some people with minimal pain and no loss of function have terrible looking x-rays.  Reciprocally, some people with significant pain have normal appearing x-rays.  We need to address the patient's symptoms, not necessarily his or her films. 

Then, why do you get an x-ray in the first place?

            If osteoarthritis is suspected as the cause of joint pain, an x-ray serves two basic purposes:

• It helps to rule out other causes of pain such as a fracture or avascular necrosis (lack of blood supply leading to bone death).
• The x-ray also gives insight into how much cartilage is left in the joint.  If the joint is relatively well preserved, we know that the pain is primarily inflammatory and should respond very well to conservative care.  If the joint space is eroded and not much cartilage is left, we know that there may be a mechanical component to the pain.  However, if there is only minimal pain and the x-ray looks "terrible" and reveals joint space erosion, we know that the patient's muscles have compensated for the joint erosion and been able to successfully unload the joint.  This patient may never need an intervention other than structured physical therapy to get him or her feeling much better. 

Sometimes, surgery must be performed for findings on imaging studies despite an absence of significant symptoms. For example, a tumor in the bone would need to be removed even if it were not causing symptoms.  An unstable fracture would need to be surgically fixed even if there were only minimal symptoms, because failure to stabilize it would lead to a bigger problem.  However, the bottom line for most osteoarthritis cases is that surgical interventions are done for symptoms and quality of life issues, not for x-ray findings.  If the pain from the joint is significant and interfering with a patient's quality of life, and if the symptoms are persistent despite aggressive conservative care, then surgical intervention may be appropriate.

            Of note, sometimes x-rays are taken for other reasons besides joint pain, and osteoarthritis is seen incidentally on the film.  X-ray findings of osteoarthritis should nevertheless prompt the patient to take steps to reduce the risk of developing worsening osteoarthritis that may eventually lead to pain and suffering if not managed.