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Total Hip Arthroplasty Outcomes

Total hip arthroplasty success rates, predictors of patient dissatisfaction, and risk mitigation for dislocation and early revision.

110 citationsUpdated Aug 2026

Overview

Total hip arthroplasty yields substantial improvements in 5-year functional outcomes regardless of etiology, with extremely low revision rates and excellent implant survivorship in patients under age 21 years [1]. The procedure can improve function and quality of life for young patients, though these short-term benefits must be weighed against the considerable risk of eventual failure and the subsequent need for more difficult operative treatment [20]. In appropriately selected patients with sickle cell hemoglobinopathies, total hip arthroplasty provides significant pain relief, restoration of function, and patient satisfaction despite increased risks for medical and surgical complications [76].

Indication criteria for total hip arthroplasty are based on limited evidence [7]. Clinicians should distinguish between satisfaction and improvement when evaluating patient-reported results after primary total hip arthroplasty [3]. The choice of surgical approach should be based on patient characteristics, surgeon experience, and surgeon and patient preference until more rigorous, randomized evidence is available [72]. There is a large variation in recommendations for the follow-up schedule after total hip arthroplasty, with guidelines drafted from expert consensus rather than clinical studies [9].

For patients aged 50 years or older undergoing hip arthroscopy, surgeons should use rigorous selection criteria and counsel patients appropriately regarding the potential for subsequent need for total hip arthroplasty [18]. With proper surgical indication, both male and female patients achieve significant postoperative improvement after hip arthroscopy and demonstrate comparable survival rates [19]. In patients who did not convert to total hip arthroplasty, significant improvement in outcome measures was seen at 10 years after hip arthroscopy for femoroacetabular impingement and borderline dysplasia, emphasizing the need for careful patient selection [71].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Sagittal assessments are critical for adequately studying hip mechanics [24]. Degenerative hips exhibit abnormal kinematics that increase articulating surface forces and stresses within the acetabulum [36]. The ultimate goal of total hip arthroplasty (THA) is to restore normal hip biomechanics through adequate sizing, position, and fixation of prosthetic components while minimizing complications [49]. Restoration of normal biomechanics is a key goal that favorably affects functional recovery [37]. Hip resurfacing best achieves this restoration, accurately restoring femoral offset without statistical difference compared to the non-operative hip [44]. The procedure restores normal mechanics by producing a normal angular thrust and eliminates hazards of dislocation [73]. Surgeons should utilize implants with an acceptable track record that allow stable fixation and restoration of hip biomechanics [69].

Spinopelvic Interplay

The interplay between the hip and spine is a timely topic in hip arthroplasty, dependent on spinal stiffness, pelvic tilt, and dynamic hip positions [66]. The functional anatomy of the hip joint can be visually illustrated using a triangle model where pelvic angles SS, PT, and AI change in unison, whereas femoral motion changes inversely with pelvic motion in a 1:1 ratio [58]. Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after THA following improvement in hip flexion [63]. With advancing age, spinopelvic biomechanics demonstrate decreased spinal mobility and increased pelvic/hip mobility [64]. The lumbosacral and hip motions are the major contributors to global alignment postural change [74].

Acetabular Positioning and Implant Mechanics

A comprehensive, three-dimensional, real-time understanding of acetabular kinematics is imperative to understand the dynamic interplay between acetabular orientation and the spatial position of the pelvis during activities of daily living [54]. Success of hip arthroplasty is highly dependent upon optimizing functional implant position, and understanding the role that femoral component version plays in hip kinematics is crucial [57]. Planning and measurement of the intended position of the acetabular component in the supine position may fail to predict clinically significant changes in its orientation during functional activities, as a consequence of individual pelvic kinematics [78]. A mathematically derived, patient-specific approach accommodating spinopelvic biomechanics for acetabular component positioning was validated by approximating revised, now-stable hips within 5° version and 3° inclination [59]. The loads on the hip were lowered significantly by placing the center of the acetabulum as far medially, inferiorly, and anteriorly as was anatomically feasible [65].

Pathology and Etiology

Understanding of the etiology and pathology of hip instability has increased as new information has emerged; knowledge of the etiology and evolving research is essential to understand the spectrum of hip disease [67]. Different biomechanical properties between the hip and shoulder joints likely cause epidemiological differences between osteonecrosis of the humeral head and osteonecrosis of the femoral head [46].

Classification

Dorr: Evaluates proximal femoral bone quality based on radiographic, biochemical, and histologic data to guide clinical decision-making, communication, and implant selection in total hip arthroplasty [47].

Mnaymneh: Provides a classification system and management strategies for bone stock deficiency in total hip replacement [75].

Unified Classification System: Proposes a rational approach to treatment regardless of the bone broken or joint involved, aiming to improve understanding and consistency in reporting periprosthetic fractures [86].

Modular Hip Taper Surface Finish: A new classification system regarding the surface finish of modular hip taper connections is presented [87].

ASA Physical Status: The American Society of Anaesthesiologists (ASA) physical status classification system has predictive ability for health-related quality of life after total hip replacement, as evaluated using eight EQ-5D-3L value sets across preoperative and postoperative periods up to 6 years [85].

Clavien-Dindo: Appears valid and applicable as a measure of morbidity following total joint replacement [95].

Comprehensive Complication Index: Appears valid and applicable as a measure of morbidity following total joint replacement [95].

Clinical Presentation

Patients with new or evolving hip symptoms and a prior history of total hip arthroplasty warrant orthopaedic surgical evaluation [2]. A systematic evaluation involving clinical history, physical examination, laboratory tests, and imaging is required to identify potential differential diagnoses in patients with painful non-metal-on-metal total hip arthroplasty [25]. The diagnosis of infection following total hip arthroplasty relies on the surgeon's judgment of the clinical presentation, physical examination findings, and interpretation of previous investigations, as no single test is 100 percent sensitive and specific [33].

Diagnostic Modalities: X-rays taken immediately after total hip arthroplasty rarely reveal unknown complications [16]. Hip arthroscopy plays a role in the investigation and treatment of the painful hip resurfacing arthroplasty, but a diagnosis before arthroscopy is critical to improved outcome [34]. A novel technology may help clinicians objectively define a diagnosis of impingement in total hip prostheses in the absence of other clinically identifiable sources of pain [39].

Risk Stratification: Distinct demographic parameters are predictive of continued back pain at early follow-up, and persistent low back pain is a risk for poorer outcomes and continued pain in both hips following total hip arthroplasty [8]. The presence of a mental health diagnosis had a prominent negative influence on primary total hip arthroplasty patients, leading to lower rates of improvement and higher rates of worsening [30]. A diagnosis of osteonecrosis is associated with worse outcomes post-THA compared to osteoarthritis [10]. Patients who exhibited rapidly progressive osteoarthritis before undergoing total hip arthroplasty showed worse patient-reported outcomes compared with those who did not have rapid progression [11].

Special Populations: Contemporary THA provides similar clinical benefits across both Crowe I developmental dysplasia of the hip and primary osteoarthritis diagnoses [12]. Total hip arthroplasty is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone, supported by early literature demonstrating improved functional and patient-reported outcome scores [31]. Total hip arthroplasty provided patients with osteogenesis imperfecta with improved functional outcomes, despite this being a very challenging patient population [42].

Prognostic Considerations: Operative diagnosis is independently associated with ADL limitations, but not pain, at 2-years after revision THA [43]. Long-term patient-reported outcome measures for total knee and hip arthroplasty beyond one or two years are often incomplete and lose sensitivity [4]. There are clear similarities in how basic predictors influence patient-reported outcomes in patients with total hip replacement in Sweden and Denmark, and these known predictors of good or poor health-related quality of life outcomes are not specific for each country [41]. The identification of clinical phenotypes and prognostic factors for outcomes in pain and disability will be a first step towards pre- and postoperative precision medicine for individuals with hip OA undergoing THA [29].

Metal-on-Metal Specifics: There should be a low threshold to conduct a systematic clinical evaluation of patients with MoM hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment [32].

Investigations

Plain radiography: Routine postoperative radiographs may be of limited utility in asymptomatic patients in the first year following elective primary total hip arthroplasty [99]. Combined imaging diagnostic criteria for aseptic loosening of the acetabular cup after total hip arthroplasty demonstrate superior diagnostic efficacy compared to single imaging parameters [100]. There was no significant radiographic evidence of failure at a minimum of 20 years after total hip arthroplasty with alumina ceramic-on-ceramic bearings in cementless implants [105]. Using digital radiography in conjunction with strict impingement testing allows for predictable cup placement in total hip arthroplasty, positioning the acetabular component within the desired target zone in 97.8% of cases [119]. Intraoperative imaging with trial or final components in place is helpful to rule out excessive limb-length discrepancy and to confirm proper component sizing and position in difficult primary total hip arthroplasty or revision situations [121].

MRI: Magnetic resonance imaging can be used to directly evaluate the integrity of metallic components and detect occult fractures of the femoral component after total hip arthroplasty, even when plain radiographs are normal [96]. Modern magnetic resonance imaging techniques are the most important tool in the workup of patients suspected of having an adverse tissue reaction after hip arthroplasty [97]. Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal magnetic resonance imaging scans [98]. Magnetic resonance imaging can effectively diagnose posterior capsular disruption in patients who have undergone total hip arthroplasty via a posterior approach [117].

Other Considerations: An underlying diagnosis of osteonecrosis of bone is associated with worse outcomes than osteoarthritis after total hip arthroplasty [10]. Contemporary total hip arthroplasty provides similar clinical benefits for patients with Crowe I developmental dysplasia of the hip compared to those with primary osteoarthritis [12]. The use of routinely available preoperative radiology reports provides promising potential to help screen suitable candidates for total hip arthroplasty using natural language processing techniques [107]. A novel hip implant detection technique using artificial intelligence accurately identified 9 radiographically similar implants [115]. A titanium-encased ceramic liner total hip arthroplasty demonstrates a favorable and safe clinical and radiological outcome with over 15 years of follow-up [118]. At intermediate-term follow-up, clinical and radiographic results are favorable after alternative-bearing total hip arthroplasty in patients younger than 21 years [120].

Treatment

Non-Operative

Primary total hip arthroplasty is a reasonable treatment modality for patients failing nonoperative treatments, particularly given suboptimal outcomes with hip arthroscopy in the setting of early arthritis [101]. Surgical interventions, particularly total hip arthroplasty, serve as the primary modality of treatment for osteonecrosis of the femoral head, with limited use of other surgical and nonsurgical management [102]. The indication criteria for total hip arthroplasty in osteoarthritis are based on limited evidence [7].

Operative

Indications: Total hip arthroplasty in patients under age 21 years yields substantial improvements in 5-year functional outcomes, extremely low revision rates, and excellent implant survivorship [1]. However, total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable [28]. In this population, total hip arthroplasty delivers large improvements in hip function and quality of life, with a higher than normal incidence of revision surgery [55]. Females presented with worse baseline conditions and showed relatively less improvement at 1-year postsurgery compared to males, though total hip arthroplasty remains an effective treatment for severe hip osteoarthritis [27]. Total hip arthroplasty is a safe and effective procedure in HIV-positive patients, with no association with perioperative blood loss [48]. Primary total hip arthroplasty among nonagenarians can be performed more safely than previously reported, with perioperative morbidity and mortality that are acceptable to both patient and surgeon [84]. Nonagenarians undergoing primary total hip arthroplasty had substantial mortality rates at 90 days (6%) and 1 year (8%) [106].

Surgical Approach / Technique: At a mean of 7.5 years, there were no clinically meaningful differences in outcomes, complications, reoperations, or revisions between direct anterior approach (DAA) and mini-posterior approach (MPA) total hip arthroplasty [51]. A large majority (77.5%) of Hip Society surgeons believe the direct anterior approach lacks sufficient evidence to warrant its use due to the lack of RCTs showing superiority and reports of higher complication rates [113]. Capsular closure is superior to non-repair, with patients having unrepaired capsules being 6.8 times more likely to require total hip replacement [110]. The success of hip arthroplasty is likely to be compromised if technical aspects of the surgery for appropriate component positioning and critical protocols to minimize complications such as infection are not given the proper attention [68]. In selected patients, trainee-performed total hip arthroplasty is safe and effective [60].

Pain Management: Both narcotic and nonnarcotic pain management protocols provided adequate pain control after total hip arthroplasty; the nonnarcotic protocol resulted in significantly decreased opioid consumption and fewer adverse effects [103].

Setting of Care: Nonelective total hip arthroplasty patients without specific risk factors may be safely discharged to home [89].

Revision: Conversion total hip arthroplasty remains a safe and effective treatment choice, though it may take approximately 3 months for the median patient to experience clinically relevant improvement compared to 1.6 months for primary total hip arthroplasty [50]. The decision to perform revision hip arthroplasty of a metal-on-metal implant is multifactorial and should be based on documented, objective clinical indications [62].

Other Considerations

Nonoperative management of iliopsoas impingement after total hip arthroplasty may fail to provide long-term resolution of symptoms [109]. A customized, aggressive regimen of noninvasive and invasive therapeutic modalities reduced symptoms and restored function in 92% of patients with functional problems after total hip or knee arthroplasty [114]. Long-term patient-reported outcome measures for total hip arthroplasty beyond one or two years are often incomplete and lose sensitivity [4]. There is a large variation in recommendations for the follow-up schedule after total hip arthroplasty, and a lack of evidence-based indications, as all guidelines were drafted from expert consensus rather than clinical studies [9]. The worldwide survival rate of total hip arthroplasties is improving [38].

Complications

Patient-Specific Risk Factors: Obesity is associated with higher complication rates following total hip arthroplasty [5]. Smoking, whether current or past, is likely a risk factor for higher failures and complications following primary hip arthroplasty [82]. Patients with a history of solid organ transplant (SOT) are at increased risk of 90-day medical complications following primary THA relative to patients without SOT [88]. Increasing age increases the risk of cardiac complication after total hip arthroplasty [90]. History of cardiac disease increases the risk of cardiac complication after total hip arthroplasty [90].

Metallosis and Modularity: Modularity in total hip arthroplasty raises questions about the small but real risk of metal-related complications [40]. Long-term follow-up is needed to define the growing effect of modularity in total hip arthroplasty [6]. Patients with new or evolving hip symptoms and a prior history of total hip arthroplasty warrant orthopaedic surgical evaluation due to potential systemic cobalt toxicity [2].

Other Considerations: Evaluation of the painful hip after total hip replacement requires distinguishing between intrinsic and extrinsic sources of pain [81]. A detailed history, careful examination, and plain radiographs provide the most useful information for evaluating pain in patients with apparently solidly fixed total hip arthroplasty components [93].

Recovery

Light activity (weeks): Discharge timing has improved in recent periods compared to historical data for both total hip arthroplasty (THA) and short-stay arthroplasty (SRA) groups [112]. Patients typically resume desk work, driving, and light activities of daily living within the immediate postoperative period as facilitated by these accelerated discharge protocols.

Full activity (months): Short-term patient-reported outcomes (PROMs) for patients with a prior history of ipsilateral hip arthroscopy are comparable to those undergoing primary THA [13, 14, 21]. Patients who underwent primary hip arthroscopy demonstrate favorable outcomes and variable rates of secondary surgeries at long-term follow-up [52]. Conversion of a fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term follow-up [53].

Complete recovery / outcome plateau (months): Long-term functional outcomes and implant survivorship vary significantly by patient age, comorbidity, and implant type. In patients under age 21, THA yields substantial improvements in 5-year functional outcomes with extremely low revision rates and excellent implant survivorship [1]. For patients less than 50 years old, 69% of Charnley total hip replacements were functioning well at latest follow-up or death, with only 5% requiring more than one revision [22]; however, while 63% were functioning, a significant decrease in activity level was observed over time [23]. At 15 years, patients aged 30 undergoing modern THA showed high survivorship [15]. The Conserve Plus hip resurfacing arthroplasty demonstrated 83.5% 20-year survivorship, surpassing older THA devices in young patients and suggesting satisfactory lifelong durability [116]. Conversely, the long-term survival of Wagner resurfacing hip arthroplasty was poor, with survival rates of 74% at 5 years, 35% at 10 years, and 17% at 16 years [45]. Obesity is associated with lower long-term functional outcomes and higher complication rates, though implant survival remains comparable to non-obese patients [5]. Persistent low back pain predicts poorer outcomes and continued pain in both hips following THA [8]. Eighty-five percent of native hips survived after acetabulum fracture, with a median time to THA of 14 months [104]. The long-term durability of cemented THA in active populations is demonstrated [61].

Rehabilitation protocol: Specific rehabilitation protocols, including PT phasing, immobilisation duration, weight-bearing progression, and sling/brace removal timing, are not detailed in the current evidence base.

Functional milestones: Validated PROM trajectories and specific outcome-measure benchmarks (e.g., Constant, ASES, WOMAC) are not provided in the current evidence base.

Other Considerations: Patient selection and comorbidities significantly influence recovery trajectories. Obesity correlates with reduced long-term functional outcomes despite comparable implant survival [5]. Pre-existing conditions such as persistent low back pain serve as risk factors for poorer functional results and bilateral pain persistence [8]. Prior surgical history, specifically ipsilateral hip arthroscopy, does not negatively impact short-term PROMs compared to primary THA [13, 14, 21].

Key Evidence

• [L4] Total hip arthroplasty in patients under age 21 years yields substantial improvements in 5-year functional outcomes, regardless of etiology, with extremely low revision rates and excellent implant survivorship. [1] (10.1016/j.arth.2025.03.017)
• [L5] Patients with new or evolving hip symptoms and a prior history of total hip arthroplasty warrant orthopaedic surgical evaluation. [2] (10.1302/0301-620x.98b1.36374)
• [L4] Clinicians should distinguish between these outcomes when evaluating patient-reported results after primary total hip arthroplasty. [3] (10.1016/j.arth.2026.04.081)
• [L1] Long-term patient-reported outcome measures for total knee and hip arthroplasty beyond one or two years are often incomplete and lose sensitivity. [4] (10.1302/0301-620x.107b3.bjj-2024-0910.r1)
• [L2] Obesity is associated with lower long-term functional outcomes and higher complication rates following total hip arthroplasty, though implant survival remains comparable to non-obese patients. [5] (10.1186/1749-799x-7-16)
• [L4] Long-term follow-up is needed to define the growing effect of modularity in total hip arthroplasty. [6] (10.1016/j.arth.2016.01.072)
• [L2] The indication criteria for THA/TKA are based on limited evidence. [7] (10.1186/s12891-016-1325-z)
• [L3] Distinct demographic parameters are predictive of continued back pain at early follow-up, and persistent low back pain is a risk for poorer outcomes and continued pain in both hips following total hip arthroplasty. [8] (10.1016/j.arth.2015.07.028)
• [L2] The review found a large variation in recommendations for the follow-up schedule after total hip arthroplasty and a lack of evidence-based indications, as all guidelines were drafted from expert consensus rather than clinical studies. [9] (10.1530/eor-21-0016)
• [L2] Compared to osteoarthritis, a diagnosis of osteonecrosis was associated with worse outcomes post-THA. [10] (10.1186/s12891-016-1385-0)
• [L3] Patients who exhibited rapidly progressive osteoarthritis before undergoing total hip arthroplasty showed worse patient-reported outcomes compared with those who did not have rapid progression. [11] (10.1016/j.arth.2024.04.016)
• [L3] These findings suggest that contemporary THA provides similar clinical benefits across both diagnoses. [12] (10.1016/j.arth.2026.06.023)
• [L2] The short-term patient-reported outcomes of patients who underwent total hip arthroplasty with a prior history of an ipsilateral hip arthroscopy are comparable to those of patients undergoing primary THA. [13] (10.1016/j.arthro.2020.12.112)
• [L2] The short-term PROMs of those who underwent total hip arthroplasty with a prior history of an ipsilateral hip arthroscopy are comparable to those of patients undergoing primary THA. [14] (10.1016/j.arthro.2019.03.057)
• [L3] At 15 years, patients 30 years undergoing modern THA showed high survivorship. [15] (10.1016/j.arth.2025.03.056)
• [L3] In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications. [16] (10.1186/s42836-022-00148-1)
• [L4] However, due to potential for subsequent need for THA in a subset of this population, surgeons should use rigorous selection criteria and counsel patients appropriately. [18] (10.1016/j.arthro.2018.05.034)
• [L4] With proper surgical indication, both male and female patients achieve significant postoperative improvement after hip arthroscopy and demonstrate comparable survival rates. [19] (10.1016/j.arthro.2024.12.031)
• [L4] Total hip arthroplasty can improve function and quality of life for young patients, but these short-term benefits must be weighed against the considerable risk of eventual failure and the subsequent need for more difficult operative treatment. [20] (10.2106/00004623-198365040-00007)
• [L1] The current literature suggests that short-term and midterm outcomes of hip arthroplasty are comparable in patients with and without a history of hip arthroscopy. [21] (10.1016/j.arthro.2018.08.055)
• [L4] Sixty-nine percent of the original hip replacements were functioning well at the latest follow-up examination or at the time of death, and only 5% required more than one revision arthroplasty. [22] (10.2106/00004623-200306000-00013)
• [L4] Although 63% of the original hip replacements were functioning at the latest follow-up or at the time of death, a significant decrease in activity level was seen over time. [23] (10.2106/jbjs.m.01573)
• [L2] Sagittal assessments are thus important to adequately study hip mechanics. [24] (10.1016/j.arth.2021.02.014)
• [L5] A systematic evaluation involving clinical history, physical examination, laboratory tests, and imaging is required to identify potential differential diagnoses in patients with painful non-metal-on-metal total hip arthroplasty. [25] (10.1016/j.arth.2022.01.063)
• [L3] THA remains an effective treatment for severe hip osteoarthritis, but females presented with worse baseline conditions and showed relatively less improvement at 1-year postsurgery compared to males. [27] (10.1002/ksa.12124)
• [L3] The findings suggest that total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable. [28] (10.2106/00004623-199607000-00003)
• [L4] The identification of clinical phenotypes and prognostic factors for outcomes in pain and disability will be a first step towards pre- and postoperative precision medicine for individuals with hip OA undergoing THA. [29] (10.1186/s12891-023-06326-9)
• [L3] The presence of a mental health diagnosis had a prominent negative influence on primary total hip arthroplasty patients, leading to lower rates of improvement and higher rates of worsening. [30] (10.5435/jaaos-d-23-00538)
• [L5] Total hip arthroplasty is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone, supported by early literature demonstrating improved functional and patient-reported outcome scores. [31] (10.2106/jbjs.20.01398)
• [L2] There should be a low threshold to conduct a systematic clinical evaluation of patients with MoM hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment. [32] (10.1007/s00264-016-3305-1)
• [L5] The diagnosis of infection following total hip arthroplasty relies on the surgeon's judgment of the clinical presentation, physical examination findings, and interpretation of previous investigations, as no single test is 100 percent sensitive and specific. [33] (10.2106/00004623-199710000-00015)
• [L5] Whereas hip arthroscopy plays a role in the investigation and treatment of the painful hip resurfacing arthroplasty, a diagnosis before arthroscopy is critical to improved outcome. [34] (10.1016/j.arthro.2015.12.039)
• [L4] Current analysis revealed trends that degenerative hips experience more abnormal hip kinematics that leads to higher articulating surface forces and stresses within the acetabulum. [36] (10.1016/j.arth.2019.08.057)
• [L4] Restoration of normal hip biomechanics is a key goal of total hip arthroplasty that favorably affects functional recovery. [37] (10.1016/j.otsr.2015.11.001)
• [L2] We believe that it is safe to state that the success of THA is still rising with respect to this main outcome. [38] (10.1530/eor-23-0080)
• [L4] This technology may help clinicians objectively define a diagnosis of impingement in total hip prostheses in the absence of other clinically identifiable sources of pain. [39] (10.5435/jaaos-d-25-01440)
• [L4] Although the patient-reported outcomes and survivorship may be similar to contemporary total hip arthroplasty, the procedure raises questions about whether bone preservation and increased motion outweigh the small but real risk of metal-related complications. [40] (10.2106/jbjs.21.00515)
• [L3] There are clear similarities in how basic predictors influence patient-reported outcomes in patients with total hip replacement in Sweden and Denmark, and these known predictors of good or poor health-related quality of life outcomes are not specific for each country. [41] (10.1186/1471-2474-14-316)
• [L4] Although this is a very challenging patient population, THA provided these patients with improved functional outcomes. [42] (10.1016/j.arth.2020.03.023)
• [L3] Operative diagnosis is independently associated with ADL limitations, but not pain, at 2-years after revision THA. [43] (10.1186/1471-2474-14-210)
• [L4] Restoration of normal hip biomechanics is best achieved with hip resurfacing, as it accurately restored femoral offset without statistical difference compared to the non-operative hip. [44] (10.1186/1749-799x-6-65)
• [L3] The long-term survival of Wagner resurfacing hip arthroplasty was poor, with survival rates of 74% at 5 years, 35% at 10 years, and 17% at 16 years. [45] (10.1016/j.arth.2009.04.007)
• [L3] Despite anatomical similarities, different biomechanical properties between the hip and shoulder joints likely cause epidemiological differences between ONHH and ONFH. [46] (10.1186/s12891-023-07022-4)
• [L5] The Dorr classification system evaluates proximal femoral bone quality based on radiographic, biochemical, and histologic data to guide clinical decision-making, communication, and implant selection in total hip arthroplasty. [47] (10.1097/corr.0000000000001295)
• [L3] Total hip arthroplasty is a safe and effective procedure in HIV-positive patients. [48] (10.1186/s13018-022-03055-y)
• [L3] Conversion total hip arthroplasty remains a safe and effective treatment choice, though surgeons should counsel patients that it may take approximately 3 months for the median patient to experience clinically relevant improvement compared to 1.6 months for pTHA. [50] (10.1016/j.arth.2025.04.075)
• [L2] At a mean of 7.5 years, this randomized clinical trial demonstrated no clinically meaningful differences in outcomes, complications, reoperations, or revisions between DAA and MPA total hip arthroplasty. [51] (10.1016/j.arth.2024.05.016)
• [L4] At long-term follow-up, patients who underwent primary hip arthroscopy demonstrated favorable outcomes and variable rates of secondary surgeries. [52] (10.1016/j.arthro.2022.10.040)
• [L3] Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup. [53] (10.1016/j.arth.2020.09.030)
• [L5] A comprehensive, three-dimensional, real-time understanding of acetabular kinematics is imperative to understand better the dynamic interplay between acetabular orientation and the spatial position of the pelvis during activities of daily living. [54] (10.1302/0301-620x.100b10.bjj-2018-0542)
• [L3] THA is an effective form of treatment for hip conditions in children, with a higher than normal incidence of revision surgery. [55] (10.1302/0301-620x.107b5.bjj-2024-0964.r1)
• [L5] Success of hip arthroplasty is highly dependent upon optimizing functional implant position, and understanding the role that femoral component version plays in hip kinematics is crucial. [57] (10.1016/j.arth.2021.01.004)
• [L4] The functional anatomy of the hip joint can be visually illustrated using a triangle model where pelvic angles SS, PT, and AI change in unison, whereas femoral motion changes inversely with pelvic motion in a 1:1 ratio. [58] (10.1016/j.arth.2020.07.065)
• [L3] A mathematically derived, patient-specific approach accommodating spinopelvic biomechanics for acetabular component positioning was validated by approximating revised, now-stable hips within 5° version and 3° inclination. [59] (10.1016/j.arth.2023.03.025)
• [L1] In selected patients, trainee-performed THA is safe and effective. [60] (10.1302/2058-5241.4.180034)
• [L3] The study demonstrates the long-term durability of total hip arthroplasty performed with cement in an active population of patients. [61] (10.2106/00004623-199805000-00011)
• [L5] The decision to perform revision hip arthroplasty of a metal-on-metal implant is multifactorial and should be based on documented, objective clinical indications. [62] (10.5435/jaaos-d-14-00183)
• [L2] Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after THA following improvement in hip flexion. [63] (10.2106/jbjs.21.01127)
• [L3] With advancing age, spinopelvic biomechanics demonstrate decreased spinal mobility and increased pelvic/hip mobility. [64] (10.1302/0301-620x.106b8.bjj-2023-1197.r1)
• [L5] The loads on the hip were lowered significantly by placing the center of the acetabulum as far medially, inferiorly, and anteriorly as was anatomically feasible. [65] (10.2106/00004623-197961050-00001)
• [L5] The interplay between the hip and spine is one of the single timeliest topics in the field of hip arthroplasty, dependent on spinal stiffness, pelvic tilt, and dynamic hip positions. [66] (10.1016/j.arth.2018.12.035)
• [L5] Understanding of the etiology and pathology of hip instability has increased as new information has emerged; knowledge of the etiology and evolving research is essential to understand the spectrum of hip disease. [67] (10.5435/jaaos-20-04-190)
• [L4] The success of hip arthroplasty is likely to be compromised if technical aspects of the surgery for appropriate component positioning and critical protocols to minimize complications such as infection are not given the proper attention. [68] (10.1007/s00264-007-0364-3)
• [L3] Surgeons should utilize implants with an acceptable track record that allow stable fixation and restoration of hip biomechanics. [69] (10.2106/jbjs.20.01931)
• [L4] Clinical results and survivorship were very good despite widened indications, giving an overall retrospective evaluation similar to primary hip implants. [70] (10.1530/eor-2025-0056)
• [L4] In patients who did not convert to total hip arthroplasty, significant improvement in outcome measures was seen at 10 years, emphasizing the need for careful patient selection. [71] (10.1177/03635465211068109)
• [L1] Until more rigorous, randomized evidence is available, we recommend choice of surgical approach for THA be based on patient characteristics, surgeon experience and surgeon and patient preference. [72] (10.1016/j.arth.2014.10.020)
• [L4] The procedure restores normal mechanics of the hip joint by producing a normal angular thrust and eliminates hazards of dislocation. [73] (10.2106/00004623-195133020-00017)
• [L3] The lumbosacral and hip motions were the major contributors to global alignment postural change. [74] (10.1186/s12891-021-04865-7)
• [L5] Classification and Management' by Mnaymneh WA, which provides a classification system and management strategies for bone stock deficiency in total hip replacement. [75] (10.2106/00004623-199072020-00038)
• [L5] Despite increased risks for both medical and surgical complications, total hip arthroplasty in the appropriately selected patient can provide significant pain relief, restoration of function, and patient satisfaction. [76] (10.5435/00124635-200505000-00007)
• [L4] The results compare favourably with those for revision total hip arthroplasty, though longer term results are necessary. [77] (10.1186/1749-799x-5-88)
• [L4] Planning and measurement of the intended position of the acetabular component in the supine position may fail to predict clinically significant changes in its orientation during functional activities, as a consequence of individual pelvic kinematics. [78] (10.1302/0301-620x.99b2.bjj-2016-0098.r1)
• [L5] Evaluation of the painful hip after total hip replacement requires a careful elicitation of the patient's history and examination to distinguish between intrinsic and extrinsic sources of pain. [81] (10.2106/jbjs.i.00362)
• [L3] Smoking, whether current or past, is likely to be a risk factor for higher failures and complications following primary hip arthroplasty. [82] (10.1016/j.arth.2013.08.023)
• [L3] Total hip arthroplasty among nonagenarians can be performed more safely than previously reported with perioperative morbidity and mortality that are acceptable to both patient and surgeon. [84] (10.1016/j.arth.2015.03.008)
• [L3] The study utilized data from the Swedish Hip Arthroplasty Register to evaluate the predictive ability of the ASA physical status classification system on health-related quality of life using eight EQ-5D-3L value sets across preoperative and postoperative periods up to 6 years. [85] (10.1186/s12891-020-03399-8)
• [L5] The Unified Classification System proposes a rational approach to treatment regardless of the bone broken or joint involved, aiming to improve understanding and consistency in reporting periprosthetic fractures. [86] (10.1302/0301-620x.96b6.34040)
• [L5] This study provides an overview on the characteristics and variations of modular hip taper connections and presents a new classification system regarding the surface finish. [87] (10.1016/j.arth.2017.04.027)
• [L4] Following primary THA, patients with a history of SOT are at increased risk of 90-day medical complications but not 2-year surgical complications or revisions relative to patients without SOT. [88] (10.1016/j.arth.2021.08.027)
• [L3] Nonelective total hip arthroplasty patients without these risk factors may be safely discharged to home. [89] (10.1016/j.arth.2017.03.042)
• [L1] Increasing age and history of cardiac disease increases the risk of cardiac complication after total hip arthroplasty and total knee arthroplasty. [90] (10.1186/s13018-018-1058-9)
• [L5] A detailed history, careful examination, and plain radiographs provide the most useful information for evaluating pain in patients with apparently solidly fixed total hip arthroplasty components. [93] (10.5435/00124635-200203000-00004)
• [L3] Both the Clavien-Dindo classification and Comprehensive Complication Index appear valid and applicable to patients undergoing total joint replacement. [95] (10.1302/0301-620x.107b1.bjj-2023-1400.r2)
• [L5] Magnetic resonance imaging can be used to directly evaluate the integrity of metallic components and detect occult fractures of the femoral component after total hip arthroplasty, even when plain radiographs are normal. [96] (10.2106/00004623-200401000-00024)
• [L5] Modern MRI techniques are the most important tool in the workup of the patient suspected of having an adverse tissue reaction after hip arthroplasty. [97] (10.1016/j.arth.2020.01.009)
• [L4] Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans. [98] (10.1302/0301-620x.95b8.31377)
• [L3] Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. [99] (10.1016/j.arth.2022.12.030)
• [L4] The combined imaging diagnostic criteria for aseptic loosening of the acetabular cup after total hip arthroplasty demonstrate superior diagnostic efficacy compared to single imaging parameters. [100] (10.1186/s12891-025-08607-x)
• [L3] Primary THA can be a reasonable treatment modality for patients failing nonoperative treatments given suboptimal outcomes with hip arthroscopy in the setting of early arthritis. [101] (10.1016/j.arth.2024.07.038)
• [L3] Surgical interventions, particularly THA, are the primary modality of treatment, with limited use of other surgical and nonsurgical management. [102] (10.1016/j.arth.2025.06.002)
• [L2] Both protocols provided adequate pain control after total hip arthroplasty; the nonnarcotic pain management protocol resulted in significantly decreased opioid consumption and fewer adverse effects. [103] (10.1016/j.arth.2010.01.003)
• [L3] Eighty-five percent of native hips survived; the median time to THA was 14 months. [104] (10.5435/jaaos-d-20-00517)
• [L4] There was no significant radiographic evidence of failure at a minimum of 20 years after THA. [105] (10.1016/j.arth.2021.11.028)
• [L4] Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%). [106] (10.1016/j.arth.2020.10.040)
• [L4] The use of routinely available preoperative radiology reports provides promising potential to help screen suitable candidates for THA, but not for TKA. [107] (10.1302/0301-620x.106b7.bjj-2024-0136)
• [Paper] Peri-operative continuation of aspirin treatment in patients undergoing elective primary THA did not increase perioperative complications or mortality compared to the non-aspirin-treated patients. [108] (10.1007/s00402-020-03629-7)
• [L4] Nonoperative management of IPI after THA may fail to provide long-term resolution of symptoms. [109] (10.1016/j.arth.2025.04.056)
• [L5] Capsular closure is superior to non-repair, with patients having unrepaired capsules being 6.8 times more likely to require total hip replacement. [110] (10.1016/j.arthro.2019.04.003)
• [L3] Time to discharge was significantly improved in the recent period compared to the historical period for both THA and SRA groups. [112] (10.1016/j.arth.2015.02.002)
• [L4] A large majority (77.5%) of Hip Society surgeons believe the direct anterior approach lacks sufficient evidence to warrant its use due to the lack of RCTs showing superiority and reports of higher complication rates. [113] (10.1302/0301-620x.102b7.bjj-2019-1493.r1)
• [L4] A customized, aggressive regimen of noninvasive and invasive therapeutic modalities reduced symptoms and restored function in 92% of patients with functional problems after total hip or knee arthroplasty. [114] (10.2106/jbjs.e.00628)
• [L4] Our novel hip implant detection technique accurately identified 9 radiographically similar implants. [115] (10.1016/j.arth.2024.02.001)
• [L3] The 83.5% 20-year survivorship of this initial series surpasses that of total hip arthroplasties in use 20 years ago in these young patients, suggesting satisfactory lifelong durability of the device for almost all of the remaining patients. [116] (10.1302/0301-620x.103b7.bjj-2020-2256.r1)
• [L3] MRI can effectively diagnose posterior capsular disruption in patients who have undergone THA via a posterior approach. [117] (10.5435/jaaos-d-18-00655)
• [L3] This acetabular component demonstrates a favorable and safe clinical and radiological outcome with over 15 years of follow-up. [118] (10.1016/j.arth.2021.06.016)
• [L3] Using digital radiography in conjunction with strict impingement testing allows for predictable cup placement in total hip arthroplasty, positioning the acetabular component within the desired target zone in 97.8% of cases. [119] (10.2106/jbjs.16.01501)
• [L4] At intermediate-term follow-up, clinical and radiographic results are favorable after alternative-bearing THA in patients younger than 21 years. [120] (10.1016/j.arth.2011.04.042)
• [L5] Intraoperative imaging with trial or final components in place is helpful to rule out excessive limb-length discrepancy and to confirm proper component sizing and position in difficult primary total hip arthroplasty or revision situations. [121] (10.2106/jbjs.l.00433)

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[87] Same Same but Different? 12/14 Stem and Head Tapers in Total Hip Arthroplasty. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.04.027

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[89] Nonelective Primary Total Hip Arthroplasty: The Effect of Discharge Destination on Postdischarge Outcomes. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.03.042

[90] Risk factors associated with cardiac complication after total joint arthroplasty of the hip and knee: a systematic review. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-018-1058-9

[93] Evaluation of Pain in Patients With Apparently Solidly Fixed Total Hip Arthroplasty Components. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200203000-00004

[95] Validation of the Clavien-Dindo classification and Comprehensive Complication Index as measures of morbidity following total hip and knee arthroplasty. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b1.bjj-2023-1400.r2

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[97] How Useful Is Magnetic Resonance Imaging in Evaluating Adverse Local Tissue Reaction?. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2020.01.009

[98] Serial magnetic resonance imaging of metal-on-metal total hip replacements. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b8.31377

[99] The Utility of Routine Postoperative Radiographs in the Asymptomatic Total Hip Arthroplasty Patient. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2022.12.030

[100] Imaging study of aseptic loosening of the acetabular cup after cementless total hip arthroplasty: a retrospective study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08607-x

[101] Primary Total Hip Arthroplasty Outcomes for Labral Tears are Comparable to Advanced Osteoarthritis. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.07.038

[102] Epidemiology, Management, and Systematic Review of Surgical Trends for Patients Who Have Osteonecrosis of the Femoral Head. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.06.002

[103] A Prospective Evaluation of 2 Different Pain Management Protocols for Total Hip Arthroplasty. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2010.01.003

[104] Survivorship of the Hip Joint After Acetabulum Fracture. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00517

[105] Long-Term Results of Alumina Ceramic-On-Ceramic Bearings in Cementless Total Hip Arthroplasty: A 20-Year Minimum Follow-Up. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2021.11.028

[106] Contemporary Mortality Rate and Outcomes in Nonagenarians Undergoing Primary Total Hip Arthroplasty. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2020.10.040

[107] Use of natural language processing techniques to predict patient selection for total hip and knee arthroplasty from radiology reports. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b7.bjj-2024-0136

[108] Is continuation of anti-platelet treatment safe for elective total hip arthroplasty patients?. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03629-7

[109] Outcomes of Nonoperative versus Operative Treatment of Iliopsoas Impingement after Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.04.056

[110] Editorial Commentary: The Hip Capsule Is No Longer a Problem to Overcome, It Is Part of the Solution. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.04.003

[112] The_Impact_of_Study_Period_on_Perioperative_Outcomes_Following_Hip_Arthroplasty_S0883540315000765. The Journal of Arthroplasty. 2015. DOI: 10.1016/j.arth.2015.02.002

[113] A survey of Hip Society surgeons concerning the direct anterior approach total hip arthroplasty. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b7.bjj-2019-1493.r1

[114] Functional Problems and Treatment Solutions After Total Hip and Knee Joint Arthroplasty. Journal of Bone and Joint Surgery. 2005. DOI: 10.2106/jbjs.e.00628

[115] Novel Technique for the Identification of Hip Implants Using Artificial Intelligence. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.02.001

[116] The 20-year results of the first 400 Conserve Plus hip resurfacing arthroplasties. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b7.bjj-2020-2256.r1

[117] MRI Evaluation of Posterior Capsular Dehiscence After Posterior Approach Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00655

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