A decision point, not a rubber stamp

Many patients arrive at a hip replacement assessment carrying a quiet anxiety: is this appointment simply the point at which the operation gets booked? The honest answer is no. A specialist hip assessment is a structured clinical evaluation with three genuinely possible conclusions — no intervention needed right now, a return to or continuation of conservative management, or a recommendation that surgery is the right next step. Which of those conclusions applies depends entirely on the clinical picture gathered during the visit itself.

The assessment typically brings together a structured conversation about symptoms and function, a physical examination of the hip, and a review of existing imaging — usually X-rays — before any recommendation is made. Nothing is confirmed before those elements are in place. At Professor Paul Lee's consultations at 108 Harley Street, that principle is made explicit: if hip replacement turns out not to be the appropriate course, that is the answer the patient leaves with. The visit is designed to answer the question many patients genuinely cannot answer alone — whether their symptoms, structural findings, and treatment history have crossed the threshold where surgery becomes the most sensible option — and to do so with clinical precision rather than assumption.

The four things a surgeon is looking for

Four clinical lenses shape the conversation at a hip replacement assessment. Every one of them needs to point in the same direction before a surgical recommendation is appropriate.

Pain and functional loss

The surgeon will explore how severely the hip is limiting daily life — whether walking, climbing stairs, sleeping, or simply standing for any length of time has become genuinely difficult. Discomfort that passes quickly or responds well to rest rarely crosses the threshold on its own; it is persistent, function-disrupting pain that carries clinical weight here.

What the imaging confirms

Symptoms are taken seriously, but they need structural evidence behind them. X-rays typically show the degree of cartilage loss, joint space narrowing, and bony change — and the surgeon is looking for findings that are consistent with what the patient is reporting. Where symptoms and imaging align, the picture becomes clearer.

The treatment trail

This part of the assessment asks what has already been tried. Physiotherapy, anti-inflammatory medication, weight management, walking aids, and injections are all part of conservative management. If those options have been genuinely attempted and found inadequate, that matters to the clinical decision. If they have not yet been properly explored, they may be recommended first.

Patient readiness and circumstances

Replacement is major surgery with a recovery that demands active participation. The surgeon will want to understand whether the patient has a realistic picture of what that involves, and whether their health, home situation, and expectations make the timing appropriate.

No single lens triggers a recommendation. It is when all four are in alignment — persistent symptoms, confirmed structural change, an inadequate conservative trail, and genuine readiness — that surgery moves from an option to the logical next step.

What your imaging shows — and why it matters

Plain X-ray remains the primary tool for assessing hip osteoarthritis because it reveals the features that matter most at this stage: joint space narrowing as cartilage is lost, changes to the bone surface, and the overall structural geometry of the hip. These findings give the surgeon a direct read on how far degeneration has progressed — and crucially, Professor Lee reviews those images during the consultation itself, not as a separate referral step afterwards.

MRI has a role, but a targeted one. In earlier-stage disease, when bone oedema or soft-tissue involvement needs clarifying, or when the X-ray findings feel inconsistent with the clinical picture, MRI can add useful detail. For established osteoarthritis with clear structural change already visible on plain film, it is not routinely required.

The most clinically important point about imaging is what it cannot do alone. Advanced joint space narrowing on an X-ray in someone whose pain is well controlled and whose function remains acceptable does not automatically indicate surgery. Equally, significant symptoms with relatively modest imaging changes may still warrant serious discussion. Imaging is interpreted in the context of everything else gathered during the assessment — it confirms the structural dimension of the clinical picture rather than dictating the conclusion on its own.

The physical examination

Before any formal recommendation is made, the surgeon will spend time examining the hip directly — moving it, loading it, and watching how the body responds. For many patients, this is the part of the appointment they feel most uncertain about; in practice, the tests are methodical and their purpose is clear.

Range of motion is assessed in several directions — flexion, rotation, and abduction — to establish where movement ends and restriction or pain begins. A hip with significant cartilage loss tends to lose internal rotation early, and reduced range of motion that mirrors the imaging findings adds important confirmation.

Gait is often observed as the patient enters or walks within the consultation room. The way someone bears weight and shifts load through a painful hip can be informative before a single question is asked.

Leg-length inequality is checked because advanced degeneration can cause measurable shortening on the affected side — something that influences both the surgical plan and implant selection if replacement is the agreed path.

Provocative tests help clarify the source of pain. Groin discomfort, in particular, can originate from several structures, and targeted manoeuvres allow the surgeon to confirm — or question — whether the hip joint itself is driving the symptoms.

Taken together, the physical examination grounds the imaging findings in lived function: it is the difference between a structural picture on film and the real-world hip in front of the surgeon.

How the final recommendation is reached

NHS guidance is clear on when hip replacement becomes appropriate: pain severe enough to significantly impair quality of life, combined with less invasive approaches that have not adequately helped. That threshold maps directly onto what the clinical assessment is designed to establish — and once it is reached, the conversation shifts naturally from evaluation to planning.

Where significant symptoms, clear structural change on imaging, and an inadequate treatment trail all align, the case for replacement is straightforward to present. Where they do not — symptoms present but imaging not yet severe, or conservative options not yet properly exhausted — an honest surgeon will say so and recommend adjusting management rather than proceeding.

The recommendation is reached jointly. The surgeon presents the clinical picture and the patient confirms they are ready to proceed. This is not a formality: a patient who understands their imaging findings, their examination results, and why prior treatment has fallen short is in a meaningfully different position when agreeing to surgery. That shared clarity also feeds directly into surgical planning — suitability for the SPAIRE muscle-sparing approach, for instance, is confirmed at this stage, so the consultation shapes not just whether to operate but how.

If the picture remains ambiguous, the appropriate outcome is continued non-surgical management with a defined review point. An assessment that concludes with adjusted physiotherapy or a return visit in six months is not a disappointment; it is the correct clinical answer for that moment in that patient's journey.

The three possible outcomes — a clear surgical plan, a structured non-surgical pathway, or onward referral for further investigation — are all clinically legitimate. The assessment exists to reach the most honest conclusion the evidence supports, not to ratify a decision made before the appointment began.

If surgery is the next step — what the assessment also determines

For patients who reach the end of that conversation with surgery as the agreed next step, the assessment has more work left to do.

Beyond confirming the decision itself, the consultation determines the most appropriate surgical approach — a detail that is easy to overlook but materially shapes the recovery. Not every patient is anatomically suited to every technique, and a surgeon who assesses and operates is better placed to make that judgement in one appointment than across several fragmented handoffs.

In this particular consultation, that includes establishing whether the patient is a candidate for SPAIRE — a muscle-sparing posterolateral approach that preserves the piriformis and obturator internus tendons rather than releasing them. Protecting those posterior soft tissues is designed to support joint stability in the early post-operative period and may allow selected patients to mobilise with greater confidence sooner after surgery. The distinction from a conventional release-and-repair approach is clinically meaningful, though whether a given patient is suitable depends on their anatomy, imaging, and overall profile.

Professor Paul Lee, who developed the SPAIRE technique at the Exeter Hip Unit under Professor Timperley, confirms suitability at the consultation itself — so the surgical plan is individualised from the outset rather than decided on the day of the operation.

For suitable patients, the biological rapid recovery programme is also introduced at this stage. Technique, implant selection, mobilisation, and recovery planning are considered together, meaning the assessment initiates the full perioperative pathway — not just the operative decision.

1. [1] Hip replacement - NHS. https://www.nhs.uk/conditions/hip-replacement/ https://www.nhs.uk/conditions/hip-replacement/