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Total hip replacement

257 citationsUpdated Oct 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Total hip arthroplasty (THA) is a definitive procedure for hip pathology, with indications spanning osteoarthritis, acute acetabular fractures, and displaced femoral neck fractures in younger, active patients [40]. The procedure is viable across the age spectrum, yielding substantial functional improvements and excellent implant survivorship in patients under 21 years [4] and beyond the ninth decade of life [176]. While THA in adolescents is reserved for carefully selected cases where alternatives are contraindicated [19], mid-term survivorship remains excellent in patients younger than 65 years [50]. Clinical outcomes for THA in acute acetabular fractures are inferior to those for osteoarthritis [30], and conversion THA may require approximately 3 months for clinically relevant improvement compared to 1.6 months for primary THA [159]. Prior hip arthroscopy does not impact subsequent THA functional outcomes [177], and setting preoperative patient-reported outcome measure thresholds does not guarantee clinically successful results [165].

Periprosthetic fracture is a recognized intraoperative complication, with acetabular fracture incidence ranging from 0.2% for cemented to 0.4% for noncemented components [1]. Intraoperative femoral fracture incidence ranges from 0.1% to 5.4% in primary THA and 3.0% to 20.9% in revision THA [1]. Surgical approach selection involves distinct efficacy-safety profiles [166]; while the direct anterior approach is utilized by more than 25% of US surgeons [3], long-term data do not confirm implant longevity or faster recovery for specific minimally invasive techniques [170]. Implant selection is individualized based on patient needs, bone quality, and surgeon experience, as no single design is universally superior [6]. Bearing surface utilization has shifted significantly, with metal-on-metal bearings decreasing from 39.2% in 2007 to 5.5% in 2015 [3], while ceramic-on-polyethylene bearings increased from 6.4% to 52.0% over the same period [3]. Cross-linked polyethylene now accounts for over 90% of acetabular liners in primary THA [3].

Perioperative protocols emphasize tranexamic acid (TXA) to reduce blood loss and transfusions, with no demonstrated increase in venous thromboembolic events [14]. Aspirin is endorsed for VTE prophylaxis due to lower bleeding risks compared to alternative chemoprophylaxis [14]. Disposition trends favor direct discharge home, with rapid recovery protocols and outpatient THA showing no increase in complications [14]. Hospital discharge within a day does not compromise 1-year outcomes for carefully selected patients [181]. Specific populations, including those with sickle cell hemoglobinopathies, can achieve significant pain relief and functional restoration despite increased medical and surgical risks [46]. Females generally present with worse baseline conditions and show relatively less improvement at one year compared to males [37].

Anatomy & Pathophysiology

Bony Anatomy and Biomechanics

The primary function of the femoral component is the replacement of the femoral head and neck after resection of the arthritic or necrotic segment [231]. Restoration of the normal center of rotation is determined by vertical height (vertical offset), medial offset (horizontal offset), and version of the taper [231]. Vertical height is determined primarily by the base length of the prosthetic neck plus the length gained by the modular head used [231]. The depth the implant is inserted into the femoral canal alters vertical height [231]. When cement is used, vertical height can be adjusted further by variation in the level of the femoral neck osteotomy [231]. Offset is the distance from the center of the femoral head to a line through the axis of the distal part of the stem and is primarily a function of stem design [231]. Inadequate restoration of offset shortens the moment arm of the abductor musculature and results in increased joint reaction force, limp, and bone impingement [231]. Bone impingement resulting from inadequate offset restoration may result in dislocation [231]. Offset can be increased by using a longer modular neck, but doing so also increases vertical height, which may result in overlengthening of the limb [231]. High offset versions of components are accomplished by reducing the neck-stem angle (typically to about 127 degrees) or by attaching the neck to the stem in a more medial position [231]. Reduction of the neck-stem offset also reduces vertical height slightly [231]. When the neck is attached in a more medial position, offset is increased without changing height, leaving leg length unaffected [231].

Version refers to the orientation of the neck in reference to the coronal plane and is denoted as anteversion or retroversion [231]. The normal femur has 10 to 15 degrees of anteversion of the femoral neck in relation to the coronal plane when the foot faces straight forward [231]. The prosthetic femoral neck should approximate the normal 10 to 15 degrees of anteversion [231]. Proper neck version is usually accomplished by rotating the component within the femoral canal [231]. When press-fit fixation is used, the femoral component must be inserted in the same orientation as the femoral neck to maximize the fill of the proximal femur and achieve rotational stability [231]. Anatomic stems have a slight proximal posterior predetermining the rotational alignment of the implant [231]. Most anatomic stems have a few degrees of anteversion built into the neck to compensate for proximal posterior positioning [231]. Separate right and left stems are required for anatomic stems with built-in anteversion [231]. Dual modular necks in different geometries and lengths allow the adjustment of length, offset, and version independently [231]. Tribocorrosion at the taper junction between the neck and stem has been reported with dual modular necks [231]. Several dual modular neck designs have been either recalled or voluntarily withdrawn from the market [231]. The use of dual modular necks has declined markedly over the past few years [231].

The size of the femoral head, the ratio of head and neck diameters, and the shape of the neck of the femoral component have a substantial effect on the range of motion of the hip [231]. Neck length is measured from center of head to base of collar [231]. Head-stem offset is measured from center of head to line through axis of distal part of stem [231]. Stem length is measured from medial base of collar to tip of stem [231]. The angle of neck is measured by intersection of line through center of head and neck with another along lateral border of distal half of stem [231]. Vertical height and offset increase as the neck is lengthened [231]. In most modern systems, neck length is adjusted by using modular heads with variable internal bores that mate with a uniformly tapered trunnion on the femoral component [231]. The taper is commonly referred to as a Morse taper, although there is no defined standard across all manufacturers [231]. A Morse taper is approximately 3 degrees on each side [231]. The most common taper used presently is 12 mm/14 mm [231]. Each manufacturer has unique specifications for their tapers that vary by diameter at the smaller and larger ends, length, taper angle, and surface finish [231]. Femoral heads from one manufacturer are not compatible with femoral trunnions of another even if the nominal size is the same [231]. Toggling of the head on the trunnion, dissociation, material loss, and corrosion may result from mismatching heads and trunnions from different manufacturers [231]. Neck length typically ranges from 25 to 50 mm [231]. Adjustment of 8 to 12 mm for a given stem size routinely is available [231]. When a long neck length is required for a head diameter up to 32 mm, a skirt extending from the lower aspect of the neck is used [231]. For heads larger than 32 mm a skirt is unnecessary even for longer neck lengths [231].

Restoration of normal hip biomechanics is a key goal of total hip arthroplasty that favorably affects functional recovery [47]. Abnormal hip and knee joint loading during walking after THR has a biomechanical background originating from hip geometry reconstruction [123]. Combinations of gait and joint positioning parameters together explained up to 86% of the variation in hip force parameters [131]. Degenerative hips experience more abnormal hip kinematics that leads to higher articulating surface forces and stresses within the acetabulum [154]. A leg length inequality in the range of 1–20 mm does not impair the symmetry of time–distance parameters and hip kinematics and kinetics during gait and stairs walking [187]. Hip offset differences greater or less than 5 mm do not significantly change gait patterns [189]. Surgical approach plays a greater role than hip offset reconstruction in producing more normal gait biomechanics following total hip arthroplasty [189]. A combination of radiological leg parameters, especially varus alignment, and deviating kinematics explain the joint moments in the frontal plane during gait after total hip replacement surgery [199]. Preoperative hip and knee kinematics differed significantly from controls, but after THA, they improved significantly and did not differ from controls [161]. Despite reduced kinetic variables in the operated hip, the joints of the non-operated limb generated similar joint kinetics as the matched control participants [227]. The lumbosacral and hip motions were the major contributors to global alignment postural change [228]. The hip morphotype had a major impact on the timing of THA [234]. MIS THR contributes to a greater symmetry of hip reaction forces in absolute value as well as force-orientation following THR [235]. The reference values for hip ROM used in previous biomechanical reports may not reflect the actual postoperative anatomic hip ROM in patients undergoing a standard THA via the posterolateral approach [236]. In vivo squatting kinematics suggest no danger of impingement or subsequent dislocation, but excessively large hip flexion and small cup anteversion remain as risks [240]. There is no benefit in hip range of movement or hip function when head sizes > 36 mm are used [247]. This CORR Insights commentary emphasizes the need for more high-quality, large-scale data and standardized biomechanical variables to better understand how joint loading is influenced by hip osteoarthritis and restored after total hip arthroplasty [248]. Additional studies are needed to determine protective or adaptive factors in patients with abnormal anatomy who do not develop early OA and to determine whether joint preserving hip surgery extends the life of the native hip joint [251]. This study supports the long-held biomechanical theory of medialisation of the acetabular component with compensatory increased femoral offset results in improved functional outcome [261]. For all the THA systems examined in this study, under the same loading conditions, a larger head leads to increasing contact areas, lower contact stresses, and higher biomechanical wear factors [262]. The authors propose a novel landmark and measurement in hip arthroplasty to restore femoral geometry and associated biomechanical forces in cases with proximal femoral bone loss [157]. 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 [168]. The results of this study highlight the importance of accurate THA component placement in optimizing hip kinematics during functional activities [171]. Intraoperative quantitative assessment of hip mechanics provides a safe and clinically relevant method to characterize potential complications and evolve techniques to prevent them [172]. This approach resulted in hip contact forces comparable to previously reported measured contact forces [174]. Despite the individualized reconstruction of the biomechanical hip geometry, objective gait analysis failed to show a benefit [130]. The study suggests that accounting for individual spine-hip kinematics improves the accuracy of component positioning [141]. Surgeons should utilize implants with an acceptable track record that allow stable fixation and restoration of hip biomechanics [219]. Studies of relative motions of hip stems should be performed using dynamic loading cycles to distinguish an initial transient phase from a steady-state phase [223]. Slightly less hip flexion was recorded with the inertial measurement units which may be due to the difference in the modelling of the pelvis, soft tissue artefacts, and malalignment between the two methods or misplacement of the inertial measurement units [243]. This study showed more normal hip kinematics and functionality in resurfacing hip arthroplasty, which may be due to the large femoral head [197].

Soft Tissue Anatomy and Nerve/Vascular Structures

The sciatic nerve travels closest to acetabulum at the level of ischium [188]. During surgery, the most common reason for sciatic nerve injury is errant retractor placement causing excess compression to nerve [188]. Peroneal nerve division is most often involved because this part of nerve is closest to acetabulum [188]. The medial femoral circumflex artery is located underneath quadratus femoris muscle or gluteus maximus tendon [188]. Cutting deep to the area of the medial femoral circumflex artery risks laceration to vessel [188]. The ascending branch of the lateral femoral circumflex artery is at risk during direct anterior approach to THA and should be ligated [188]. The ascending branch of the lateral femoral circumflex artery passes upward beneath tensor fasciae latae and is encountered in the space between tensor fasciae latae and sartorius [188]. The transverse acetabular ligament extends between the two cotyloid pads at the inferior aspect of the acetabulum [188]. Errant retractor placement inferior to the transverse acetabular ligament can damage obturator artery and vein [188]. The literature indicates a potential role for the hip joint capsule in mechanics via mechanoreceptors, though nomenclature is inconsistent and proprioceptive roles cannot be reliably confirmed as no study has reported type I-III mechanoreceptors [255].

The abductor mechanism of the hip is composed of the gluteus medius and minimus muscles and is integral for normal gait and hip stability [382]. Prior studies have likened the abductors of the hip to the rotator-cuff in the shoulder, coining the term “rotator-cuff tear of the hip” [382]. Tearing of the broad insertion on the greater trochanter was described as analogous to large tears of the supraspinatus and infraspinatus tendons [382]. One series reported a 22% rate of abductor mechanism tear at surgery for treatment of displaced femoral neck fractures [382]. Howell et al found a prevalence of 20% in patients undergoing THA for osteoarthritis [382]. There was a higher incidence of abductor tears in women and patients of advanced age [382]. The etiology of abductor tears after THA is multifactorial and includes physiological degenerative tearing, iatrogenic failed repair after THA, and postoperative tearing [382]. Patients with preoperative tears masked by their articular hip pathology represent one category of abductor tear patients [382]. Patients who have a failed repair of the abductors after anterolateral approach for THA represent a second category of abductor tear patients [382]. Those with intact tendons preoperatively who undergo an abductor-sparing technique with a tear that develops postoperatively represent a third category of abductor tear patients [382]. Superior displacement of the hip center caused a 13% decrease in the moment arm of the abductors and a 43% decrease in their force-generating capacity [218]. Multiple mechanisms have been proposed to result in symptomatic iliopsoas tendinitis [334]. A subset of patients may present with idiopathic iliopsoas tendinitis after THA without clear radiographic pathology or technical error [334].

Spinopelvic Biomechanics

Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after THA following improvement in hip flexion [27]. Disturbances in spinal and pelvic kinematics lead to abnormal hip function, which may contribute to complications following total hip arthroplasty (THA) [164]. 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 [200]. 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 [211]. 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 [232].

Implant Fixation and Interface Mechanics

Polymethylmethacrylate (PMMA) is used for cement fixation [52]. Biologic fixation secures the implant via bone growth into the prosthesis [52]. Bone ingrowth utilizes a porous coating [52]. Bone ongrowth utilizes a grit coating [52]. A porous-coated cementless cup is the preferred choice for cup fixation [52]. Porous-coated hemispheric cementless cups have reliable long-term results that are superior to cemented cups [52]. Screws may be used to supplement fixation but have not been found to be necessary with good initial stability of cup [52]. Both cementless and cemented fixation methods are acceptable techniques in primary THA for the stem [52]. Cementless stem indications include high-activity-level patients because cement would cyclically fatigue over time [52]. Cementless stem indications include young male patients because higher loading stress would cause cement cracks at stress points [52].

The canal of the femur is prepared with serial reaming and/or broaching to achieve desired implant size, remembering that cortical contact is preferred [63]. An implant of slightly larger size is impacted into position for press fit technique [63]. The stem usually has a gradual wedge taper [63]. The wedging effect generates compression hoop stresses that hold the implant still to allow bone to grow into the implant interface [63]. The acetabulum is prepared with serial hemispheric reamers to achieve desired implant size, reaming to cortical margin of acetabular rim [63]. An implant of slightly larger size is impacted into position for press fit technique in the acetabulum [63]. The wedge effect occurs at the rim of the acetabulum [63]. The compression hoop stress generated at the rim holds the implant still to allow bone to grow into the implant interface [63].

Prosthetic surface is prepared by blasting of the surface with an abrasive grit material for bone ongrowth fixation [63]. Grit blasting process creates microdivots with no pores, just divots [63]. Divot diameter is approximately the same size as pore hole for a porous-coated implant [63]. Bone grows onto rough surface, stabilizing prosthesis [63]. Ra is defined as average peak to valley on the surface of the implant [63]. Implant roughness determines strength of biologic fixation [63]. There is a linear relation of Ra to fixation strength [63]. Initial rigid fixation of implant is always a press fit technique for bone ongrowth [63]. Femoral stem design is typically a high-angle, double-wedge taper (wedge in both coronal and sagittal planes) for bone ongrowth [63]. Grit surface is extensile [63]. Fixation strength with grit blast fixation is significantly lower than that with porous coating [63]. The area of surface coating is greater for grit blast fixation due to lower fixation strength [63]. There are very few cups designed with bone ongrowth surface coating [63]. Aseptic loosening is a complication of bone on

Classification

Periprosthetic Fractures

Paprosky: The Paprosky classification is used for periprosthetic fractures of the acetabulum associated with total hip arthroplasty [1].

Unified Classification System (UCS): The UCS for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts [213].

Greater Trochanter Fracture Classification: A new classification system for isolated greater trochanter fractures associated with total hip arthroplasty is based on fracture location relative to insertional anatomy [126].

BOSTI Hip: The BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty [167].

Bone Stock and Deficiency

Femoral Deficiency Algorithm: A classification system and algorithmic approach exists to guide femoral reconstruction in revision total hip arthroplasty based on the type of femoral deficiency [107].

Acetabular Bone Loss: A validated classification system for acetabular bone loss guides treatment and prognosticates outcomes in revision total hip arthroplasty [179].

Bone Stock Deficiency: A classification system and management strategies exist for bone stock deficiency in total hip replacement [151].

Mallory: The Mallory classification is used to grade preoperative femoral bone quality in revision total hip arthroplasty [294]. Hips with type-IIIA femoral bone quality according to the Mallory classification had a significantly higher rate of failure secondary to aseptic loosening than hips with type-II femoral bone quality [294].

Paprosky (Acetabular Defects): The Paprosky classification is used to assess acetabular bone defects during revision surgery for failed hip resurfacing [336].

Heterotopic Ossification

Brooker: The Brooker classification is a radiographic grading system for heterotopic ossification that categorizes bone formation into Grade I (islands of bone), Grade II (bone spurs with ≥1 cm separation), Grade III (bone spurs with <1 cm separation), and Grade IV (osseous ankylosis) [64]. The Brooker classification for heterotopic ossification has been reported to have low interobserver reliability and little clinical relevance [64].

Modified Brooker: The modified Brooker classification for heterotopic ossification includes Grade A (no bone formation), Grade B (bone islands with 1 cm separation), and Grade C (ankylosis or bone spurs with <1 cm separation) [64].

Implant and Component Design

Modular Hip Taper Surface Finish: A classification system regarding the surface finish of modular hip taper connections has been presented [155].

Femoral Stem Length: A classification system for the length of femoral stems has been suggested to organize discussion on stem length in primary total hip replacement [158].

Cementless Femoral Fixation: A basic classification system for cementless femoral fixation in total hip arthroplasty categorizes stems into six types, with a separate classification recommended for short-stem designs [325].

Preoperative and Patient Classification

Hip-Spine: The Hip-Spine Classification system guides the use of dual mobility components in patients with spinopelvic pathology to reduce the risk of dislocation [224].

ASA Physical Status: The American Society of Anaesthesiologists (ASA) physical status classification system has been evaluated for its predictive ability on health-related quality of life after total hip replacement [210].

Long-term Unreduced Dislocation: A new classification system for long-term unreduced hip joint dislocation, secondary osteoarthritis, and pseudoarthrosis could help surgeons estimate potential difficulties during total hip arthroplasty [16].

DRG Reclassification: Conversion total hip arthroplasty is supported for reclassification into a diagnosis-related group separate from primary total hip arthroplasty [42].

Cartilage and Labral Pathology

Outerbridge: The Outerbridge classification is used to grade femoral head and acetabular cartilage damage in patients undergoing hip arthroscopy [319].

Beck: The Beck classification is used to grade labral damage and transition zone cartilage injury in patients undergoing hip arthroscopy [319].

Clinical Presentation

Indications and Contraindications

The primary indication for total hip arthroplasty (THA) is the alleviation of incapacitating arthritic pain that cannot be sufficiently relieved by non-surgical alternatives [7]. Surgery is justified when pain at rest and during motion or weight bearing is severe enough to prevent work or activities of daily living despite conservative measures [7]. Pain associated with a degenerative or destructive process in the hip joint, as evidenced on imaging, constitutes the primary surgical indication [7]. Patients presenting with limitation of motion, limp, or leg-length inequality with little or no hip pain are not candidates for THA [7]. Historically, patients aged 60 to 75 years were considered the most suitable candidates, but this age range has expanded since the 1990s [7]. The 1994 National Institutes of Health Consensus Statement concluded that THA is an option for nearly all patients with hip diseases causing chronic discomfort and significant functional impairment [7].

THA is increasingly offered for the management of hip osteoarthritis in patients with fragile or pathologic bone [24]. It serves as a reliable treatment for alleviating pain and improving function in patients with advanced symptomatic arthritis secondary to osteochondrodysplasia [41]. In the setting of severe symptoms and the absence of advanced osteoarthritis on radiographs, advanced imaging can guide treatment and select patients who could benefit from THA [35].

Absolute contraindications include active infection of the hip joint or any other region and unstable medical illnesses that significantly increase the risk of morbidity or mortality [7]. A documented patent ductus arteriosus or septal defect is an absolute contraindication for bilateral total hip procedures carried out under a single anesthetic [7]. Asymptomatic bacteriuria is not associated with postoperative surgical site infections and should not be considered a contraindication for THA [7].

Preoperative Evaluation and History

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 [85]. 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 [17]. If the cause of persistent pain is not obvious after a thorough history, physical examination, and plain radiographic evaluation, further investigation including serologic tests, sophisticated radiologic investigations, nuclear medicine scans, and microbiologic investigations is required [23].

Pain localization guides the differential diagnosis. Groin or buttock pain suggests an acetabular or a joint-centered problem [15]. Anterior thigh pain suggests a femoral-side problem [15]. Lateral hip pain suggests hip abductor weakness, trochanteric impingement, or inflammation such as bursitis or tendinopathy [15]. Knee pain may indicate a hip condition, while patient-reported hip pain may be referred from the lumbar spine, abdomen, or retroperitoneum [15].

Temporal patterns of pain provide further diagnostic clues. Early-onset and/or unresolved pain may indicate infection, occult fracture, or a mechanically unstable prosthesis [15]. Delayed-onset pain is more likely to be the result of low-grade surgical infection, late hematogenous infection, bearing surface wear, synovitis, osteolysis, mechanical loosening, or stress shielding and loss of periprosthetic bone [15]. Start-up pain or pain with prolonged ambulation is associated with weight-bearing activities [15]. Pain while lying on the side suggests bursitis, abductor weakness, tendinopathy, or tear [15]. Prolonged drainage after surgery, fever, and chills are suggestive of infection [15]. A history of hip dislocation suggests instability [15]. A history of multiple procedures is associated with increased risks of infection and instability [15].

Pain associated with loose total hip components typically occurs with the first few steps a patient takes, known as start-up pain [9]. A loose acetabular component usually produces pain in the groin, whereas a loose femoral component may cause pain in the thigh or knee [9]. The differential diagnosis of persisting unusual symptoms after total hip replacement must include a fistula between the total hip prosthesis and urinary tract, even in the absence of open sinuses [127]. Vascular injury during total hip replacement can present as an acute abdominal condition without pronounced local symptoms [145].

Physical Examination

Physical examination findings for the painful THA include localization of pain and tenderness, range of motion in flexion, abduction, and rotation arcs, and comparison of femoral version with the contralateral hip [15]. Pain with active hip flexion may suggest psoas tendon irritation or anterior impingement [15]. Hip abduction weakness may contribute to lateral hip pain and may originate from a neurologic condition, violation of hip abductors from surgery, or inadequate rehabilitation [15]. Neurologic assessment of motor and sensory function may indicate peripheral nerve injury or concurrent lumbar radiculopathy [15]. Vascular assessment includes checking distal pulses, warmth, and perfusion [15]. Patient history, physical examination, and radiological studies provide the surgeon with almost all the data required to stratify a patient according to risk for postoperative THA instability [122].

Imaging Studies

Plain radiographs should be taken in perpendicular planes, and the AP view should allow visualization of the contralateral hip [15]. Radiographic signs of loosening include component migration or subsidence, progressive or complete radiolucency, absence of spot welding, pedestal formation in the femur, and bone stock maintained in the femoral neck with calcar sclerosis [15]. Acetabular osteolysis is characterized by size and location using the Charnley and DeLee classification system, which includes zone 1 (superolateral), zone 2 (central), and zone 3 (inferomedial) [15]. Plain radiographs underestimate the severity of acetabular osteolysis [15]. Ancillary radiographs such as Judet views or CT scans are important to assess the integrity of the anterior and posterior columns in acetabular osteolysis [15]. Femoral osteolysis is characterized by size and location using the Gruen classification system, which includes zones 1 through 7 progressing from proximal/lateral distally to the tip of the implant and back up the medial side to the lesser trochanter [15].

CT provides assessment of component position and anteversion, the size and location of bone loss, and the quality and location of remaining bone [15]. MRI with artifact reduction may be useful in identifying soft-tissue lesions around the hip joint [15]. Ultrasonography may be useful in identifying soft-tissue masses around failed implants [15]. Nuclear medicine may indicate the presence of components that are not osseointegrated [15].

In periprosthetic acetabular fractures, plain radiographs may underestimate bone loss [1]. Judet views (obturator and iliac oblique radiographs) may help identify an anterior or posterior column fracture [1]. The fracture line may be obscured by metallic components [1]. Bone scans may help identify late periprosthetic acetabular fractures not seen on plain radiographs [1]. However, bone scans may show areas of increased uptake for 1 to 2 years postoperatively in the absence of fracture [1]. CT is seldom needed for periprosthetic acetabular fractures but may help visualize fractures not identified using other imaging methods [1]. For periprosthetic femoral fractures, a minimum of two views (AP and lateral) are obtained to help identify the type and extent of the fracture [1]. X-rays taken immediately after surgery rarely reveal unknown complications in total hip arthroplasty [26]. Hip arthroscopy may be useful in the diagnosis and treatment of apparently well-implanted but unstable total hip replacement prostheses [11]. 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 [21].

Laboratory Assessment

The erythrocyte sedimentation rate (ESR) is a nonspecific indicator of a chronic or acute inflammatory state, and an ESR greater than 20 mm/hr suggests an inflammatory state [15]. The C-reactive protein (CRP) level is a nonspecific indicator of acute infection and usually normalizes within 3 weeks of surgical intervention [15]. A CRP level greater than 7.0 mg/L suggests an acute inflammatory process [15]. Complete blood cell count with differential may be elevated with systemic infection or illness [15].

For chronic postoperative joint aspiration, a white blood cell (WBC) count greater than 2,500 cells/mL and polymorphonuclear leukocytes (PMNs) greater than 90% are indicative of infection [15]. For acute postoperative joint aspiration, a WBC count greater than 27,000 cells/mL and PMN values greater than 90% are indicative of infection [15]. Lower PMN values may be considered if the clinical picture supports infection, such as elevated ESR or CRP levels [15].

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 [81]. The final diagnosis of periprosthetic joint infection is based on the interpretation of the clinical presentation and preoperative and intraoperative findings rather than on a single test [129]. A diagnosis of periprosthetic joint infection is made when the patient meets at least one of three criteria: an open wound or sinus in communication with the joint, a systemic infection with pain in the hip and purulent fluid within the joint, or a positive result on at least three tests where either histological evaluation or intraoperative cultures had to be positive [129].

Specific Clinical Scenarios

There should be a low threshold to conduct a systematic clinical evaluation of patients with metal-on-metal hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment [92]. The true incidence of trunnionosis in metal-on-polyethylene total hip arthroplasty is likely underreported due to variable clinical presentations and unclear pathogenesis [147]. 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 [140]. Early periprosthetic femoral fracture after total hip arthroplasty represents a distinct clinical phenotype defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity [146]. Instability after total hip arthroplasty may be more common than is generally recognized [148]. Hip arthroscopy after hip arthroplasty is uncommon but occurs more frequently in female patients, is undertaken in a broad age range of patients, and often is associated with a diagnosis of iliopsoas or hip tendinitis [132]. The history, physical examination, and diagnostic workup of extra-articular sources of pain after total hip arthroplasty include iliopsoas impingement, greater trochanteric pain syndrome, and deep gluteal space pathology [117].

Investigations

History and Physical Examination

The pattern of pain localizes the pathology in the post-arthroplasty hip. Groin or buttock pain suggests an acetabular or joint-centered problem [15], while anterior thigh pain indicates a femoral-side issue [15]. Lateral hip pain points to hip abductor weakness, trochanteric impingement, or inflammation such as bursitis or tendinopathy [15]. Pain characteristics further refine the differential: pain with hip flexion may indicate decreased combined anteversion or a horizontal component of impingement [15], whereas pain with hip extension suggests increased combined anteversion or a vertical component of impingement [15]. Pain while lying on the side suggests bursitis, abductor weakness, tendinopathy, or tear [15].

Temporal onset distinguishes etiology. Early-onset and/or unresolved pain may indicate infection, occult fracture, or a mechanically unstable prosthesis [15]. Delayed-onset pain is more likely to result from low-grade surgical infection, late hematogenous infection, bearing surface wear, or stress shielding and loss of periprosthetic bone [15]. A history of post-surgical antibiotic treatment suggests infection [15]. Weakness in hip abduction may contribute to lateral hip pain and may originate from a neurologic condition, violation of hip abductors from surgery, or inadequate rehabilitation [15]. If the cause of persistent pain is not obvious after a thorough history, physical examination, and plain radiographic evaluation, further investigation is required [23]. 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 [21].

Imaging Studies

Plain radiography: In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications [26]. Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA [259]. Plain radiography had the highest diagnostic accuracy in the evaluation of aseptic loosening of the acetabular component [346]. 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 [272]. After THA, acetabular component position can be evaluated using a variety of imaging techniques [291]. Weight-bearing imaging is a critical adjunct to traditional supine radiographs for optimizing total hip arthroplasty component position to prevent instability and early wear [328]. 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 [326]. Patients awaiting THA and having combined high hip and reduced lumbar spine mobility can be screened for with lateral standing radiographs of the spinopelvic complex [341]. AI-based analyses can accurately and consistently evaluate postoperative THA radiographs [344]. In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA [35]. Radiographic evidence of FAI is common in active patients with hip complaints [365]. A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy within 2 years [20].

CT: CT may be useful for creating models for reconstruction or customized implants [15].

Magnetic Resonance Imaging (MRI)

MRI: Selective use of MRI could be invaluable in directing the care of patients after hip arthroplasty [169]. 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 [204]. Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans [225]. MRI can effectively diagnose posterior capsular disruption in patients who have undergone THA via a posterior approach [302]. MRI can accurately describe adverse local tissue reaction (ALTR) in modular femoral neck total hip arthroplasty [305]. MARS-MRI is as suitable as standard diagnostic tools to distinguish between aseptic failure and periprosthetic joint infection (PJI) in patients with THA [358]. If the diagnosis of trochanteric bursitis is not apparent, a metal artifact reduction sequence (MARS) MRI can be used to confirm this condition [304].

Laboratory Assessment

Laboratory: The C-reactive protein (CRP) level is a nonspecific indicator of acute infection, usually normalizes within 3 weeks of surgical intervention, and a level greater than 7.0 mg/L suggests an acute inflammatory process [15]. Lower PMN values may be considered if the clinical picture supports infection, such as elevated ESR or CRP level [15]. Diagnosis of trunnionosis is made based on serum cobalt level > 1 ppb and cobalt ions >>> chromium ions [8].

Assessment for Adverse Reaction to Metal Debris (ARMD)

ARMD: ARMD may occur with hip reconstructions performed with large metal-on-metal articulations, dual-modular femoral necks, and/or large diameter femoral heads [15]. Factors associated with increased metal particle generation include acetabular implant malposition, reduced or excessive clearance between the head and acetabulum, corrosion at modular junctions and head-neck taper, smaller femoral head size (<46 mm) in hip resurfacing, and female sex [8]. Biologic reaction to metal wear products is T cell mediated and can result in synovitis, acute lymphocyte vasculitis–associated lesions, and pseudotumor formation [8].

Bone Quality and Preoperative Assessment

Other Considerations: Over half of patients had osteoporosis; however, only 15.3% of patients had a DEXA scan before THA [362]. Intraoperative trabecular torque measurements may function as an intraoperative alternative to DXA in THA, though more research and clinical trials are necessary before clinical use [357]. Results suggest focusing on preoperative function and radiological osteoarthritis to decide when THA will be most effective [335]. Compared to osteoarthritis, a diagnosis of osteonecrosis was associated with worse outcomes post-THA [36]. These findings suggest that contemporary THA provides similar clinical benefits across both Crowe I developmental dysplasia of the hip and primary osteoarthritis diagnoses [32]. National implant registers define the epidemiology of primary and revision surgery and, in conjunction with individual subjective patient data and radiography, contribute to the development of evidence-based THA surgery [13].

Treatment

Non-Operative

Conservative measures, including weight loss, nonopioid analgesics, activity modification, low-impact exercise, and ambulatory aids, should be advised before major reconstruction [7]. THA is indicated when non-operative management fails to adequately control symptoms, including severe pain on movement, disturbed sleep, pain at rest, functional limitations during activities of daily living, and reduced walking distance [55].

Operative

Indications: Total hip arthroplasty (THA) is the definitive treatment for end-stage hip osteoarthritis, which accounts for over 90% of THA procedures in Europe [55]. Surgery is justified when pain at rest and with motion or weight bearing is severe enough to prevent work or activities of daily living, particularly in the presence of a degenerative or destructive process on imaging [7]. In younger individuals, hip preservation options such as femoral or periacetabular osteotomy should be considered if the joint is not grossly incongruous and satisfactory motion is present [7]. Arthrodesis remains a viable option for young, vigorous patients with unilateral hip disease, especially young active men with osteonecrosis or posttraumatic arthritis [7]. THA in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable [19]. THA is an effective treatment for hip conditions in children, though it carries a higher than normal incidence of revision surgery [143]. Joint-preservation techniques should be utilized in very young patients to facilitate future hip arthroplasty surgery [94]. THA is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone [24]. THA is feasible for the treatment of the three types of congenital hip disease when appropriate techniques and implants are used [25]. THA for developmental dysplasia of the hip is a technically demanding surgery requiring an in-depth understanding of anatomical abnormalities [75]. THA is a safe and feasible option for head and neck of femur fractures secondary to civilian gunshot injuries that carry poor surgical fixation outcomes [196]. THA with cement fixation provides good early clinical results for femoral neck fracture nonunion but demonstrates durability problems, particularly in younger patients [198]. Primary THA may be the management of choice for rheumatoid patients and young patients unsuitable for internal fixation of displaced subcapital femoral fractures [212]. THA may be considered for younger and more active patients with displaced femoral neck fractures based on expert opinion [40]. Conversion of failed hip internal fixation to THA is clinically successful but carries an elevated risk of complications [216]. THA is a cost-effective option compared to non-operative management in patients 80 years old and older [237]. Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%) [56]. The presence of cerebral palsy is not a contraindication for total hip replacement for a painful deformed or degenerated hip [125]. THA provided systematic alleviation of pain in non-ambulatory cerebral palsy patients without aggravating functional status, though with a non-negligible rate of complications [281]. THA in non-ambulatory patients with cerebral palsy requires caution and a multidisciplinary team approach due to a high complication rate (35%) and risk of revision [290]. THA is an attractive solution for non-ambulatory patients with cerebral palsy to relieve pain [290]. THA is effective for the treatment of high dislocation of the hip in adults [102]. THA can be a reasonable treatment modality for patients with labral tears failing nonoperative treatments, given suboptimal outcomes with hip arthroscopy in the setting of early arthritis [254]. THA is an option for patients with acute acetabular fractures, though clinical outcomes are inferior to those of THA for osteoarthritis [30]. Acute THA with or without concurrent fracture fixation may improve outcomes in select patients with identifiable risk factors for acetabular fractures [195]. Percutaneous column fixation and THA is an alternative to traditional combined ORIF and THA for acute acetabular fractures in the elderly, mitigating complications associated with extensive surgical approaches [80]. THA is a safe procedure in patients with sickle cell hemoglobinopathies, providing significant pain relief and function restoration despite increased risks for medical and surgical complications [46]. THA should be performed in patients with ankylosing spondylitis when the disease is stable, as active disease increases blood loss [111].

Surgical Approach / Technique: The most common surgical approaches for THA include anterior (Smith-Petersen), anterolateral (Watson-Jones), lateral (Hardinge), posterolateral, and mini-posterior [5]. The anterior approach uses the internervous interval between the superficial sartorius/femoral nerve and tensor fasciae latae/superior gluteal nerve, and the deep rectus femoris/femoral nerve and gluteus medius/superior gluteal nerve [5]. Structures at risk in the anterior approach include the lateral femoral cutaneous nerve and the ascending branch of the lateral femoral circumflex artery [5]. The anterior approach allows hip dislocation without risk to the femoral head blood supply and provides useful anterior column exposure [5]. The anterior approach limits posterior acetabular visualization and extensive release of abductors can result in weakness and a high incidence of heterotopic ossification [5]. The anterolateral (Watson-Jones) approach uses the internervous interval between the tensor fasciae latae (femoral nerve) and gluteus medius (femoral nerve) [5]. Structures at risk in the anterolateral approach include a branch of the superior gluteal nerve supplying the tensor fasciae latae and the femoral nerve [5]. The anterolateral approach has a low incidence of postoperative dislocation and good exposure of the hip joint and proximal femur without trochanteric osteotomy [5]. Risks of the anterolateral approach include damage to the femoral shaft, malpositioning of the femoral implant, and damage to the abductors [5]. The lateral (Hardinge) approach involves splitting the gluteus medius at the junction of the anterior third and posterior two-thirds [5]. The transtrochanteric lateral (Charnley) approach accesses the joint through osteotomy of the greater trochanter [5]. The lateral approach provides access to the anterior and posterior hip joint without trochanteric osteotomy and has a low rate of postoperative dislocation [5]. Disadvantages of the lateral approach include postoperative limp (18% incidence in primary THA), heterotopic ossification (incidence as high as 47% in primary THA), increased intraoperative time and blood loss, and slower rehabilitation [5]. Trochanteric nonunion rates for the lateral approach are reported between 5% and 32% [5]. The posterolateral approach has no internervous plane and places the sciatic nerve at risk [5]. The posterolateral approach offers minimal anatomic disruption, excellent exposure of the socket and femur, quick recovery, and a lower rate of reported overall complications [5]. The posterolateral approach is associated with a slightly higher dislocation rate [5]. The direct anterior approach (DAA) is utilized by more than 25% of US surgeons [3]. Large registry and multi-institution studies have shown the anterior approach can be performed safely without an increase in complications in experienced hands [3]. Abductor sparing approaches through the Watson Jones muscle interval have gained popularity as an alternative to the DAA with similar lower pain levels and faster recovery [3]. The DAA is associated with a higher rate of femoral problems, including fracture and loosening [273]. The posterior approach is associated with a higher rate of dislocation [273]. All three surgical approaches (posterior, direct lateral, and direct anterior) are safe and have excellent results in patients undergoing primary THA [78]. Promoting one surgical approach over another is marketing without substantial proof of superiority; surgical technique, clinical experience, and modern-day pathways play the most substantial roles in providing excellent care [72]. The choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience [95]. The DAA may be comparable to other THA approaches, but there is no evidence to date that shows improved long-term outcomes for patients [86]. Patients who received primary THA via the direct anterior approach were more likely to receive revision THA via a discordant approach compared to other primary approaches [76]. Revision THA through the direct anterior approach is technically challenging but offers advantages in exposure of the acetabulum and can yield generally good postoperative function [79]. The two-incision technique for THA uses a small direct anterior approach for acetabular exposure and a small posterior approach for femoral preparation [257]. The two-incision technique is a technically demanding procedure that requires careful patient selection, preoperative templating, and attention to details to avoid potential complications [87]. The two-incision technique offers the opportunity to obtain the benefits of modern hip arthroplasty with the advantage of a shorter recovery and quicker rehabilitation [87]. Every two-incision total hip replacement caused measurable damage to the abductors, the external rotators, or both [274]. Damage to the muscle of the gluteus medius and gluteus minimus was substantially greater with the two-incision technique than with the mini-posterior technique [274]. Minimally invasive total hip arthroplasty is a safe procedure in skilled hands that does not increase complication rates compared to traditional approaches [82]. The mini-anterior approach is a safe, minimally invasive method for performing primary total hip replacement that encourages early functional recovery [103]. A modified direct anterior approach preserves the benefits of the anterior approach while addressing practical limitations such as the need for a traction table and specialised equipment [89]. The surgical approach impacts the component selection in THA [106].

Implant Selection: No implant design or system is appropriate for every patient; selection is based on patient needs, anticipated longevity, activity level, bone quality, implant availability, and surgeon experience [6]. Cementless biologic fixation remains the benchmark for revision THA [310]. Modular and nonmodular fluted tapered stems offer reliable fixation in revision THA even when bone stock is significantly compromised [310]. A 2017 single-institution study reported a 96% 10-year survivorship among 519 aseptic femoral revisions where a modular fluted tapered stem was utilized [310]. Noncemented hemispherical highly porous acetabular cups with supplemental screw fixation are sufficient for most acetabular revisions [310]. Porous tantalum acetabular cup and augment constructs offer the potential for excellent long-term fixation for major acetabular bone loss [310]. A 2017 study reported 97% survivorship at 5 years among 85 hips revised with significant acetabular bone loss using a porous tantalum construct [310]. Cup-cage constructs provide excellent short-term results for complex acetabular defects, including those with concurrent pelvic discontinuity [310]. Custom triflange constructs and pelvic distraction remain good options for complex acetabular defects [310]. Porous-coated cementless cups are the preferred choice for acetabular fixation [52]. Both cementless and cemented fixation methods are acceptable techniques in primary THA for the femoral stem [52]. Cementless stem indications include high-activity-level patients and young male patients, as cement would cyclically fatigue over time or crack at stress points [52]. Cemented fixation of the femoral component is preferred in patients with poor bone and/or those with a femoral neck fracture due to a lower rate of periprosthetic fracture [273]. Cemented stems have a lower risk of periprosthetic fracture in patients with poor bone (often elderly females) and Dorr C anatomy [333]. Cementation of the femoral stem in hip fracture patients may facilitate better postoperative mobilization [333]. In patients older than 65 years undergoing primary THA, cemented femoral fixation resulted in the lowest incidence rate of early periprosthetic femur fracture [202]. While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including more elderly patients [163]. Uncemented and antibiotic-loaded cemented fixations remain options for the prevention of prosthetic joint infection in primary total hip replacement [215]. The results of a 15-year study encouraged the continued use of cementless fixation in total hip arthroplasty [185]. A straight-stemmed, plasma-sprayed, titanium-alloy, uncemented femoral component afforded durable fixation at ten to twelve years after primary THA [153]. Implant survivorship at 2, 5, and 10 years for a specific uncemented primary THA system is among the best reported for any total hip system in the world [51]. Surgeons should consider possible later hip conversion and results when choosing the appropriate fixation implant [203]. The Corin C-Fit uncemented total hip arthroplasty implant should not be used, and patients who have had this form of THA should be kept under regular review [160]. Bone ingrowth requires live host bone, an appropriate ingrowth surface on the implant, and initial rigid fixation [273]. Motion of the prosthesis within the bone will lead to fibrous fixation or encapsulation [273]. Hydroxyapatite is an osteoconductive surface coating that may shorten the time to biologic fixation [273]. Femoral stress shielding leads to loss of proximal bone density and results from modulus mismatch between stem and femoral bone [273]. Femoral stem breakage occurs from cantilever bending [273]. The incidence of implant fractures after THA in worldwide arthroplasty register datasets is 304 fractures per 100,000 implants [45]. One out of 323 patients undergoes revision surgery due to an implant fracture after THA in their lifetime [45]. Over 90% of acetabular liners used in primary THA in 2015 were made of cross-linked polyethylene (XLPE) [3]. Long-term data support a marked decrease in wear, osteolysis, and revision surgery beyond 15 years with XLPE compared with conventional polyethylene [3]. Utilization of metal-on-metal bearings decreased from 39.2% to 5.5% between 2007 and 2015 [3]. Utilization of ceramic-on-polyethylene bearings increased from 6.4% to 52.0% between 2007 and 2015 [3]. There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients [142]. Gender factors influence the success of metal-on-metal THA, leading to expanded contraindications to avoid this device in female patients [135]. All patients undergoing implantation of metal-on-metal hips since 2006 and those with bilateral MoM hips should undergo regular investigation, regardless of symptoms [149].

Adjuncts: Tranexamic acid (TXA) has become standard-of-care at most institutions performing hip arthroplasty for its benefit in reducing surgical blood loss and subsequent transfusions [14]. There is a dose-dependent relationship between blood transfusions and subsequent development of periprosthetic joint infection [14]. Oral TXA was equally effective as IV administration but at a greatly reduced cost [14]. A combined IV and topical application of TXA reduced total blood loss by an additional 200 mL compared with the

Complications

Periprosthetic fracture: Acetabular periprosthetic fractures occur in 0.4% of primary THA cases with noncemented components [1]. Intraoperative risks include poor bone quality, underreaming by more than 2 mm, and use of elliptical monoblock components [1]. Postoperative risks include trauma and osteolysis [1]. Imaging may require Judet views or bone scans to identify fractures missed on plain radiographs [1]. Management is dictated by fracture type and stability. For Type IA (intraoperative, nondisplaced), the cup is retained and augmented with screws, with protected weight bearing for 8 to 12 weeks [1]. For Type IB (intraoperative, displaced), the cup is removed, fragments are fixed, and a multipole revision implant is used [1]. Type II fractures during implant removal may be managed with a large revision implant if 50% of host bone remains intact [1]. Traumatic Type IIIA fractures with stable components are managed with protected weight bearing [1]. Unstable Type IIIB fractures require revision to a porous implant and pelvic plate fixation if the posterior column is involved [1]. Spontaneous Type IVA fractures (<50% bone loss) are treated with a large revision implant and bone graft [1]. Type IVB fractures (>50% bone loss) require bulk allograft or metallic augmentation, potentially with a cage construct [1]. Pelvic discontinuity (Type V) requires pelvic plate fixation; Type VB and VC (associated with radiation) utilize cemented implants, cages, or custom triflange components due to poor biologic fixation potential [1].

Femoral periprosthetic fractures occur in 0.1% to 5.4% of primary THA and 3.0% to 20.9% of revision THA [1]. Risk factors include revision surgery, press-fit techniques, compromised bone stock, and impaction grafting [1]. Prophylactic cerclage wires and cortical onlay strut allografts are recommended to reduce risk during impaction grafting [1]. The cumulative incidence of femoral fracture after primary uncemented THA reaches the rate of aseptic stem loosening in the third decade [350]. No specific risk factors were identified in a 20-year follow-up study of primary uncemented THA [350]. A decade after primary THR, fractures occur in 26 per 10,000 persons annually, especially in those with prior knee or hip revision surgery [370]. Preoperative hormone replacement therapy in postmenopausal women is associated with lower fracture rates and does not increase venous thromboembolism risk [399]. Early fractures carry higher risks of infection and reoperation compared to late fractures [406].

Instability: Dislocation risk is influenced by implant orientation and patient factors. Target acetabular abduction is 30° to 50° and anteversion is 5° to 25° [8]. High abduction with high anteversion causes anterior instability in extension, while low abduction with low anteversion causes posterior instability in flexion [8]. Combined anteversion targets are 35° to 40° for females and 30° to 35° for males [8]. Decreased femoral offset and inadequate leg length restoration lead to impingement and reduced abductor efficiency [8]. Patient factors increasing risk include female sex, osteonecrosis, femoral neck fractures, spinal fusion, and limited lumbar mobility [8]. Revision THA carries higher dislocation risk than primary THA [8]. Patients with spinal deformity or fixed spinopelvic alignment have markedly increased instability risk [3]. Pre-existing spinal fusion surgery warrants consideration of measures to reduce complication risk [397].

Management of acute dislocation typically involves closed reduction [8]. Well-aligned components may be treated with increased head size, dual-mobility constructs, trochanteric advancement, or constrained liners [8]. Component revision is indicated for malalignment or inability to restore offset and length with retained components [8]. Femoral head sizes >36 mm reduce dislocation rates but are associated with increased groin pain, higher polyethylene wear in active patients, and head-neck junction corrosion or loosening [8]. No difference in revision rates for dislocation or aseptic causes exists between dual mobility constructs and large femoral head bearings in primary THA [364].

Infection (PJI): Periprosthetic joint infection risk is elevated by multiple surgical procedures, uncontrolled diabetes, morbid obesity, inflammatory arthritis, malnutrition, smoking, chronic immunosuppression, and longer operative times [8]. Antibiotic prophylaxis should be administered within 1 hour before skin incision [8]. Allogeneic transfusion may independently increase infection risk [8]. The risk of PJI following primary THA has remained unchanged over 15 years despite improvements in other outcomes [287]. Aseptic reoperations within 1 year of primary THA increase subsequent PJI risk by 8- to 13-fold [343]. PJI within 1 year is associated with over a fivefold increased mortality risk within 10 years [390]. Patients revised for infection have higher mortality than those undergoing primary THA or aseptic revision [348]. PJI carries significantly higher mortality than major aseptic revisions [413]. Mortality after THA PJI is 11.0% within three years, comparable to 5-year rates for breast and prostate cancers [416].

Cefazolin prophylaxis is associated with lower 90-day PJI rates compared to alternative antibiotics [396]. Antibiotic-impregnated cement reduces infection rates by approximately 50% in primary hip arthroplasty [398]. Thirty percent of primary total hip prostheses are placed in sites contaminated with bacteria before insertion [420]. Previous infection 0 to 6 months before primary THA does not increase PJI revision risk [386]. Sepsis within one year of THA is associated with elevated PJI and mortality rates [403]. High PJI incidence follows THA with concomitant or previous hardware removal [401]. Higher-than-expected infection rates are observed after revision of metal-on-metal THAs [408]. Patient factors have strong independent associations with PJI revision rates, while surgical factors are less important but more modifiable [423]. Increasing BMI is associated with long-term PJI risk [414]. Bearing choice does not influence PJI risk [415]. The one-year infection rate after primary total hip replacement was in control [355].

Aseptic loosening: Periprosthetic osteolysis is a macrophage-initiated response to submicron polyethylene wear debris [8]. Linear pattern osteolysis is associated with cemented and mechanically unstable components, leading to migration or subsidence [8]. Focal pattern osteolysis involves expansile lesions accessing areas of incomplete implant fixation [8]. Late cemented component loosening relates to cement mantle quality, thickness (2-mm minimum), varus femoral stem position, and particle access [8]. Initial stability is essential for osseointegration of noncemented components; subsidence results from inadequate stability [8]. Higher loosening rates may occur with large femoral heads in noncemented components [8]. A minimum of 35% ingrowth is required for acetabular fixation in noncemented components [8]. A femoral implant may have mechanical stability without osseointegration [8].

Aseptic loosening is the most common cause of reoperation following primary THA [367]. The Taperloc femoral component is associated with low aseptic loosening rates at 20 years [300]. The 15-year survivorship for nonmodular flexible press-fit cups is 95.3% overall and 97.5% for aseptic loosening [378]. THA in patients with long-standing hip fusion has a higher mechanical failure and loosening rate (approximately 40%) than primary arthroplasty [301]. Complications of revision for mechanical failure after cemented THA include femoral cortex perforation (13%), deep infection (3.4%), dislocation (8.2%), trochanteric complications (6.2%), and sciatic palsy (0.7%) [318]. Femoral loosening correlates with varus positioning (50%), inadequate cement (34%), and young age (16%) [318]. Acetabular loosening is attributed to high cup placement (41%), inadequate bone (18%), vertical cup orientation (7%), and poor cementing technique (3%) [318].

Other Considerations: The overall complication rate for custom triflange acetabular components in revision THA is 29% [337]. The most common complications are dislocation (11%), PJI (6%), nerve injury (3.8%), and wound complications (2.7%) [337]. The 10-year survivorship for revision THA using second revision as an endpoint is 82% [68]. Contemporary aseptic revision THAs in patients ≤50 years have a re-revision risk of approximately 1 in 4 at 20 years [371]. Long-term outcomes of cemented primary and subsequent revision THA are promising in patients under 50 years [347]. Patients report higher rates of worsening and lower rates of improvement following revision THA compared to primary THA, with significantly less score improvement and lower postoperative scores for all patient-reported outcome measures [54]. Primary THA achieves minimal clinically important difference significantly faster than revision THA across multiple patient-reported outcome measures [71]. Early aseptic revision THA is associated with significantly higher 90-day complication rates and 2-year rerevision rates compared to primary THA without revision [359]. At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017 [12]. The most common indications for revision are dislocation, mechanical loosening, other mechanical problems, infection, osteolysis, periprosthetic fracture, wear, and implant failure or breakage [9]. Pain is the major indication for revising a THA [9]. Revision is indicated for progressive stem deformation or incomplete fracture [9]. Left untreated, a deformed stem ultimately fractures completely, making revision more difficult due to the need to retrieve the distal segment from the medullary canal [9]. Surgery for adverse local tissue reaction generally yields poor results, with high rates of infection, instability, and reoperation [9]. In a series of 309 primary THAs in patients with ankylosing spondylitis, the 20-year cumulative incidence of any revision was 17.5% [327]. The incidence of preoperative DVT in non-fracture patients was 3.1%, with 2.4% in primary THA and 9.0% in revision THA [298].

Recovery

Light activity (weeks): Most patients who have had a right total hip arthroplasty recover sufficient hip function to return to driving 4 to 6 weeks postoperatively [112]. With modern surgical techniques and rehabilitation protocols, patients can, on average, return to safely braking a vehicle approximately 2 weeks after right total hip arthroplasty [271].

Full activity (months): The majority of patients undergoing total hip replacement can expect to return to work and sporting activities within 4-6 months [156]. Most patients are able to return to preoperative levels of low- and moderate-impact sports between 7 and 12 months after total hip arthroplasty [221]. At a minimum five-year follow-up, most patients who underwent DAA THA successfully returned to sporting activities, typically within six months postoperatively [410].

Complete recovery / outcome plateau (months): While THA patients had more severe pain preoperatively, they experienced more immediate improvements in their pain outcomes, achieved an earlier plateau in their scores, and had lower postoperative pain than TKA patients [394]. These results support the conclusion that six months following surgery, the gait of the majority (85%) of THA patients has not returned to normal [412]. After surgery, individuals with total hip arthroplasty displayed a persistent increased contralateral shift as compared to controls, indicating the need for rehabilitation focused on normalizing loading of the limbs [263].

Rehabilitation protocol: Postoperative physical therapy remains an essential component of standard care following total joint arthroplasty, but the specific approach should be individualized [217]. In patients having unilateral total hip replacement, supervised and independent postdischarge rehabilitation did not differ for improving pain and function [253]. A randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required [280]. Self-efficacy-enhancing interventions are recommended to be combined with routine care soon after hip replacement [277]. Standard physiotherapy rehabilitation in the UK after total hip replacement is variable and appears to rarely include progressive resistance training (PRT) [269]. A rapid rehabilitation protocol is safe and fulfills the potential benefits of a rapid recovery with minimally invasive total hip arthroplasty [226]. The benefits of same-day discharge total hip arthroplasty can be safely extended to the carefully indicated and motivated Medicare patient [239]. Rapid discharge following total hip arthroplasty can be performed safely in select patients older than 70 [241]. While same-day discharge after primary total hip arthroplasty is associated with low overall readmission rates, smoking and advanced age confer disproportionately greater readmission risk when same-day discharge is pursued [252]. Short-term recovery favors limited incision over standard incision THA [437]. These data suggest that increased travel distance to treatment centers does not markedly impact outcomes following primary THA [249].

Functional milestones: Maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA [433]. Functional outcomes improved significantly, with the median Oxford Hip Score increasing from 8 preoperatively to 32 at follow-up for custom-made acetabular implants in complex revision total hip arthroplasty [434].

Other Considerations: 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 in patients less than fifty years old [53]. Primary THA in AS patients demonstrated favorable survival at 10 years but poor long-term survival [70]. 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 in patients less than fifty years old [391]. Patients who had undergone total hip arthroplasty have impaired long-term self-reported physical quality of life and hip functionality but they still perform physically better than untreated patients with advanced hip osteoarthritis [283]. Total hip arthroplasty proved to be reliable for alleviating pain and improving function in patients with advanced symptomatic arthritis of the hip secondary to osteochondrodysplasia [41]. Patients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia [435]. Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup [430]. Variable functional recovery and a relatively high complication rate, particularly with tapered stems, warrant caution in Crowe Type IV dysplasia, as not all patients achieve optimal results [431]. Patients who had prior lumbar spine surgery who underwent primary THA demonstrated equivalent improvements in PROs, but achieved lower overall postoperative scores and met hip arthroplasty thresholds at lower rates [432]. At one year after primary THA, at least 13% of Danish patients experienced moderate to severe postsurgical pain [266]. Despite greater improvements on PROMs from preoperative to postoperative, patients undergoing early revisions after primary THA perceive significantly higher levels of pain and worse physical functionality at 1-year of follow-up [419]. The majority of patients return to work after THA, and some patients are able to start working after surgery [175]. Total hip arthroplasty has positive effects on work capacity in patients who return to work [194]. Fifty-nine percent of patients returned to some form of recreational activity after total hip arthroplasty [191]. Hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play [208]. Total hip arthroplasty is unlikely to significantly deleteriously affect participation and performance in golf after an appropriate period of recovery, with patients having a good chance of returning to play approximately 6 months after operation [258]. The majority of patients were able to maintain their physical activity level in the long term after primary cementless THA, compared with the activity level before the onset of restricting osteoarthritis symptoms [250]. Most patients resumed or exceeded preoperative activity, and many previously inactive patients participated in sports after THA [404]. Survivorship for revision total hip arthroplasty using second revision as an endpoint was 82% at 10 years [68]. This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement [407].

Key Evidence

• [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. [2] (10.5435/jaaos-d-14-00183)
• [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. [4] (10.1016/j.arth.2025.03.017)
• [L4] Hip arthroscopy may be useful in the diagnosis and treatment of apparently well-implanted but unstable total hip replacement prostheses. [11] (10.1016/j.arthro.2009.11.013)
• [L4] At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017. [12] (10.2106/jbjs.20.01235)
• [L4] National implant registers define the epidemiology of primary and revision surgery and, in conjunction with individual subjective patient data and radiography, contribute to the development of evidence-based THA surgery. [13] (10.1097/01.blo.0000193517.19556.e4)
• [L4] The new classification system could help surgeons estimate potential difficulties during total hip arthroplasty. [16] (10.1186/s12891-020-03678-4)
• [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. [17] (10.1016/j.arth.2022.01.063)
• [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. [19] (10.2106/00004623-199607000-00003)
• [L3] A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy within 2 years. [20] (10.1186/s12891-019-2646-5)
• [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. [21] (10.5435/jaaos-d-25-01440)
• [L5] [23] (10.5435/00124635-200203000-00004)
• [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. [24] (10.2106/jbjs.20.01398)
• [L3] In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications. [26] (10.1186/s42836-022-00148-1)
• [L2] Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after THA following improvement in hip flexion. [27] (10.2106/jbjs.21.01127)
• [L4] As clinical outcomes continue to be inferior to those of THA for osteoarthritis, larger multicentre studies are required to investigate possible differences between surgical indications and techniques. [30] (10.1302/0301-620x.107b8.bjj-2024-1232.r1)
• [L3] These findings suggest that contemporary THA provides similar clinical benefits across both diagnoses. [32] (10.1016/j.arth.2026.06.023)
• [L3] In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA. [35] (10.1016/j.arth.2024.05.043)
• [L2] Compared to osteoarthritis, a diagnosis of osteonecrosis was associated with worse outcomes post-THA. [36] (10.1186/s12891-016-1385-0)
• [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. [37] (10.1002/ksa.12124)
• [L1] However, total hip arthroplasty may be considered for younger and more active patients based on expert opinion. [40] (10.1016/j.arth.2024.10.085)
• [L4] Nonetheless, total hip arthroplasty proved to be reliable for alleviating pain and improving function in patients with advanced symptomatic arthritis of the hip secondary to osteochondrodysplasia. [41] (10.2106/00004623-200402000-00012)
• [L3] These results support the reclassification of conversion into a diagnosis-related group separate from primary THA. [42] (10.1016/j.arth.2020.12.023)
• [L3] Because of their reported higher risks, there is no clear indication for modularity with a primary THA, unless the hip center cannot be achieved with a nonmodular stem. [43] (10.1007/s11999-013-3361-4)
• [L1] The incidence in worldwide arthroplasty register datasets is 304 fractures per 100,000 implants, meaning one out of 323 patients undergoes revision surgery due to an implant fracture after THA in their lifetime. [45] (10.1007/s00264-013-2110-3)
• [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. [46] (10.5435/00124635-200505000-00007)
• [L4] Restoration of normal hip biomechanics is a key goal of total hip arthroplasty that favorably affects functional recovery. [47] (10.1016/j.otsr.2015.11.001)
• [L4] The results compare favourably with those for revision total hip arthroplasty, though longer term results are necessary. [48] (10.1186/1749-799x-5-88)
• [L4] Total hip arthroplasty performed in young and presumed active patients younger than 65 years has excellent survivorship at the mid-term follow-up. [50] (10.5435/jaaosglobal-d-22-00256)
• [L3] Implant survivorship at 2, 5, and 10 years is among the best reported for any total hip system in the world. [51] (10.1016/j.arth.2020.01.063)
• [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. [53] (10.2106/00004623-200306000-00013)
• [L3] Patients reported higher rates of worsening and lower rates of improvement following revision total hip arthroplasty than primary total hip arthroplasty, with significantly less score improvement and lower postoperative scores for all patient-reported outcome measures after revision. [54] (10.1016/j.arth.2023.05.053)
• [L4] Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%). [56] (10.1016/j.arth.2020.10.040)
• [L5] [64] (10.5435/jaaos-d-22-01070)
• [L4] Survivorship for revision total hip arthroplasty using second revision as an endpoint was 82% at 10 years. [68] (10.1007/s11999-008-0566-z)
• [L4] Primary THA in AS patients demonstrated favorable survival at 10 years but poor long-term survival. [70] (10.5435/jaaosglobal-d-25-00115)
• [L3] Primary total hip arthroplasty achieves minimal clinically important difference significantly faster than revision total hip arthroplasty across multiple patient-reported outcome measures. [71] (10.1016/j.arth.2024.10.002)
• [L5] Promoting one surgical approach over another is marketing without substantial proof of superiority; surgical technique, clinical experience, and modern-day pathways play the most substantial roles in providing excellent care during total hip arthroplasty. [72] (10.2106/jbjs.21.01047)
• [L5] Total hip arthroplasty for developmental dysplasia of the hip is a technically demanding surgery requiring an in-depth understanding of anatomical abnormalities and complex techniques. [75] (10.1186/s42836-019-0004-6)
• [L3] Patients who received primary total hip arthroplasty via the direct anterior approach were more likely to receive revision total hip arthroplasty via a discordant approach compared to other primary approaches. [76] (10.1016/j.arth.2023.06.040)
• [L5] All three surgical approaches (posterior, direct lateral, and direct anterior) are safe and have excellent results in patients undergoing primary total hip arthroplasty. [78] (10.1016/j.arth.2024.10.036)
• [L4] Revision total hip arthroplasty through the direct anterior approach is technically challenging but offers advantages in exposure of the acetabulum and can yield generally good postoperative function. [79] (10.2106/jbjs.j.01736)
• [L4] This novel technique served as an alternative to traditional combined ORIF and THA, mitigating complications associated with extensive surgical approaches. [80] (10.1016/j.arth.2013.08.009)
• [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. [81] (10.2106/00004623-199710000-00015)
• [L5] Minimally invasive total hip arthroplasty is a safe procedure in skilled hands that does not increase complication rates compared to traditional approaches, with short-term results being the same as long incisions. [82] (10.1097/blo.0b013e3181468766)
• [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. [85] (10.2106/jbjs.i.00362)
• [L5] The direct anterior approach (DAA) may be comparable to other total hip arthroplasty approaches, but there is no evidence to date that shows improved long-term outcomes for patients. [86] (10.5435/jaaos-d-20-00334)
• [L5] The two-incision total hip arthroplasty is a technically demanding procedure that requires careful patient selection, preoperative templating, and attention to details to avoid potential complications, but it offers the opportunity to obtain all the benefits of modern hip arthroplasty with the advantage of a shorter recovery and quicker rehabilitation. [87] (10.1097/01.blo.0000192361.00227.6f)
• [L5] This modified approach preserves the benefits of the anterior approach while addressing practical limitations such as the need for a traction table and specialised equipment, offering a versatile, safe, and accessible option for primary and selected revision total hip arthroplasty. [89] (10.1186/s13018-025-06397-5)
• [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. [92] (10.1007/s00264-016-3305-1)
• [L4] Joint-preservation techniques should be utilized to facilitate future hip arthroplasty surgery. [94] (10.5435/jaaos-20-08-487)
• [L1] Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience. [95] (10.1016/j.arth.2016.08.027)
• [L4] The authors believe that this operative technique of total hip arthroplasty is effective for the treatment of the difficult condition of high dislocation of the hip. [102] (10.2106/00004623-199804000-00007)
• [L3] The ASI approach is a safe, minimally invasive method for performing primary total hip replacement that encourages early functional recovery. [103] (10.1302/0301-620x.96b11.34348)
• [L3] The surgical approach impacts the component selection in THA. [106] (10.1016/j.arth.2023.08.066)
• [L4] The authors present a classification system and algorithmic approach to guide femoral reconstruction in revision total hip arthroplasty, recommending specific implant strategies based on the type of femoral deficiency to ensure stability and osseointegration. [107] (10.2106/00004623-200300004-00001)
• [L3] It is strongly recommended to perform THA in AS patients with stable disease. [111] (10.1186/s12891-020-03278-2)
• [L3] Most patients who have had a right total hip arthroplasty have recovered sufficient hip function to return to driving 4 to 6 weeks postoperatively. [112] (10.1097/01.blo.0000072468.32680.ff)
• [L4] The paper details the history, physical examination, and diagnostic workup of extra-articular sources of pain after total hip arthroplasty, including iliopsoas impingement, greater trochanteric pain syndrome, and deep gluteal space pathology. [117] (10.5435/jaaosglobal-d-25-00226)
• [L4] [122] (10.1016/j.arth.2018.01.047)
• [L2] Abnormal hip and knee joint loading during walking after THR has a biomechanical background originating from hip geometry reconstruction. [123] (10.1016/j.arth.2019.07.027)
• [L4] The presence of cerebral palsy is not a contraindication for either hip arthrodesis or total hip replacement for a painful deformed or degenerated hip. [125] (10.2106/00004623-198668040-00017)
• [L5] This review outlines management strategies for isolated greater trochanter fractures associated with total hip arthroplasty, proposing a new classification system based on fracture location relative to insertional anatomy to inform treatment recommendations for intraoperative, postoperative, primary, and revision settings. [126] (10.5435/jaaos-d-23-00560)
• [L5] The differential diagnosis of persisting unusual symptoms after total hip replacement has to include a fistula between the total hip prosthesis and urinary tract, even in the absence of open sinuses. [127] (10.1007/bf00454733)
• [L1] [129] (10.1186/1749-799x-3-31)
• [L3] Despite the individualized reconstruction of the biomechanical hip geometry, objective gait analysis failed to show a benefit. [130] (10.1007/s00402-008-0717-4)
• [L3] Combinations of gait and joint positioning parameters together explained up to 86% of the variation in hip force parameters. [131] (10.1002/jor.20935)
• [L4] Hip arthroscopy after hip arthroplasty is uncommon but occurs more frequently in female patients, is undertaken in a broad age range of patients, and often is associated with a diagnosis of iliopsoas or hip tendinitis. [132] (10.1016/j.asmr.2024.100987)
• [L3] Gender factors, potentially hormonal, anatomic, or functional, influence the success of metal-on-metal THA, leading the authors to expand contraindications to avoid this device in female patients. [135] (10.1016/j.arth.2011.04.012)
• [L4] Among young THA patients, postoperative complication rates varied by indication; however, long-term implant survival is reassuring regardless of surgical indication—with 10-year survival at approximately 94% for all groups analyzed. [137] (10.5435/jaaosglobal-d-25-00042)
• [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. [140] (10.1016/j.arth.2024.04.016)
• [L3] The study suggests that accounting for individual spine-hip kinematics improves the accuracy of component positioning. [141] (10.1016/j.otsr.2019.02.012)
• [L2] There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients. [142] (10.1302/0301-620x.97b9.34824)
• [L3] THA is an effective form of treatment for hip conditions in children, with a higher than normal incidence of revision surgery. [143] (10.1302/0301-620x.107b5.bjj-2024-0964.r1)
• [Case_report] Vascular injury during total hip replacement can present as an acute abdominal condition without pronounced local symptoms, leading to delayed treatment and fatal outcomes. [145] (10.2106/00004623-199310000-00020)
• [L5] Early periprosthetic femoral fracture after total hip arthroplasty is not simply the same fracture occurring sooner but represents a distinct clinical phenotype defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity. [146] (10.2106/jbjs.26.00128)
• [L4] The review evaluates the incidence, pathogenesis, diagnosis, and treatment of trunnionosis in metal-on-polyethylene total hip arthroplasty, noting that the true incidence is likely underreported due to variable clinical presentations and unclear pathogenesis. [147] (10.1016/j.arth.2018.05.035)
• [L3] Instability after total hip arthroplasty may be more common than is generally recognized. [148] (10.2106/00004623-198264090-00004)
• [L3] We recommend all patients undergoing implantation since 2006 and those with bilateral MoM hips undergo regular investigation, regardless of symptoms. [149] (10.1302/0301-620x.99b5.bjj-2016-1232.r1)
• [L5] Classification and Management' by Mnaymneh WA, which provides a classification system and management strategies for bone stock deficiency in total hip replacement. [151] (10.2106/00004623-199072020-00038)
• [L3] Our results show that hip arthroscopy, when performed in patients with the appropriate indications, can lead to comparably excellent outcomes as total hip arthroplasty with significant pain relief at short term follow-up. [152] (10.1016/j.asmr.2022.06.013)
• [L4] This femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty. [153] (10.2106/00004623-200401000-00014)
• [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. [154] (10.1016/j.arth.2019.08.057)
• [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. [155] (10.1016/j.arth.2017.04.027)
• [Paper] The majority of patients undergoing total hip replacement can expect to return to work and sporting activities within 4-6 months. [156] (10.1007/s00402-013-1700-2)
• [L4] The authors propose this novel landmark and measurement in hip arthroplasty to restore femoral geometry and associated biomechanical forces in cases with proximal femoral bone loss. [157] (10.5435/jaaosglobal-d-22-00149)
• [L4] The authors suggest a classification system for the length of femoral stems to better organize the discussion on stem length. [158] (10.1302/0301-620x.96b4.33036)
• [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. [159] (10.1016/j.arth.2025.04.075)
• [L3] We believe this implant should not be used and patients who have had this form of total hip arthroplasty should be kept under regular review. [160] (10.1007/s00402-007-0557-7)
• [L3] Preoperative hip and knee kinematics differed significantly from controls, but after THA, they improved significantly and did not differ from controls. [161] (10.1002/jor.25421)
• [L3] While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. [163] (10.1302/0301-620x.104b2.bjj-2021-1199.r1)
• [L4] Disturbances in spinal and pelvic kinematics lead to abnormal hip function, which may contribute to complications following total hip arthroplasty (THA). [164] (10.1016/j.otsr.2023.103773)
• [L3] Setting preoperative PROM thresholds for THA eligibility did not guarantee clinically successful outcomes. [165] (10.1016/j.arth.2022.09.004)
• [L1] THA surgical approaches present distinct efficacy-safety profiles with varying probabilities of advantage. [166] (10.1186/s12891-026-09683-3)
• [L2] The proposed BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during THA. [167] (10.1302/0301-620x.106b9.bjj-2024-0529.r1)
• [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. [168] (10.1186/1749-799x-6-65)
• [L4] Selective use of MRI could be invaluable in directing the care of patients after hip arthroplasty. [169] (10.1016/j.arth.2008.04.023)
• [L4] There is insufficient evidence to conclusively support the hypothesis that a specific surgical approach or minimally invasive technique provides faster recovery and return to function after total hip arthroplasty, and long-term data do not exist to confirm implant longevity. [170] (10.2106/jbjs.i.00343)
• [L4] The results of this study highlight the importance of accurate THA component placement in optimizing hip kinematics during functional activities. [171] (10.1002/jor.22837)
• [L4] Intraoperative quantitative assessment of hip mechanics provides a safe and clinically relevant method to characterize potential complications and evolve techniques to prevent them. [172] (10.1016/j.arth.2007.07.004)
• [L4] This approach resulted in hip contact forces comparable to previously reported measured contact forces. [174] (10.1080/10255842.2016.1181174)
• [L1] The majority of patients return to work after THA, and some patients are able to start working after surgery. [175] (10.1186/s13018-023-03578-y)
• [L3] Overall, THA remains a safe and viable treatment modality beyond the ninth decade of life. [176] (10.1016/j.arth.2020.03.026)
• [L3] With the numbers available, prior hip arthroscopy does not appear to have an impact on the functional outcomes of a subsequent THA. [177] (10.1016/j.arth.2016.01.008)
• [L4] The authors present a validated classification system for acetabular bone loss that guides treatment and prognosticates outcomes. [179] (10.1016/j.arth.2007.05.020)
• [L3] For those that qualify after careful selection, outpatient THA might be a feasible alternative to the traditional inpatient THA. [181] (10.1016/j.arth.2019.10.059)
• [L3] Uncemented total hip arthroplasty is a viable option for the elderly patient with an excellent rate of implant survival. [184] (10.1016/j.arth.2017.01.029)
• [L4] The results encouraged the continued use of cementless fixation in total hip arthroplasty. [185] (10.2106/00004623-200306000-00015)
• [L3] A leg length inequality in the range of 1–20 mm does not impair the symmetry of time–distance parameters and hip kinematics and kinetics during gait and stairs walking. [187] (10.1007/s00264-009-0855-5)
• [L3] Hip offset differences greater or less than 5 mm do not significantly change gait patterns, and surgical approach plays a greater role than hip offset reconstruction in producing more normal gait biomechanics following total hip arthroplasty. [189] (10.1016/j.arth.2023.08.040)
• [L3] Fifty-nine percent of patients returned to some form of recreational activity after total hip arthroplasty. [191] (10.5435/jaaosglobal-d-21-00160)
• [L3] Total hip arthroplasty has positive effects on work capacity in patients who return to work. [194] (10.1016/j.arth.2008.11.011)
• [L4] In the select patient with identifiable risk factors, acute total hip arthroplasty with or without concurrent fracture fixation may be able to improve outcomes. [195] (10.5435/jaaos-d-24-01541)
• [L4] Total hip arthroplasty is a safe and feasible option for these complex injuries that carry poor surgical fixation outcomes. [196] (10.1016/j.injury.2025.112753)
• [L3] This study showed more normal hip kinematics and functionality in resurfacing hip arthroplasty, which may be due to the large femoral head. [197] (10.1016/j.arth.2006.03.010)
• [L3] Total hip arthroplasty with cement fixation provides good early clinical results but demonstrates problems with durability, particularly in younger patients and when using first-generation cementing techniques. [198] (10.2106/00004623-200410000-00019)
• [L2] A combination of radiological leg parameters, especially varus alignment, and deviating kinematics explain the joint moments in the frontal plane during gait after total hip replacement surgery. [199] (10.1186/s12891-019-2832-5)
• [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. [200] (10.1016/j.arth.2023.03.025)
• [L3] In patients older than 65 years of age undergoing primary THA, cemented femoral fixation resulted in the lowest incidence rate of early PPF. [202] (10.1016/j.arth.2023.10.020)
• [L3] Surgeons should consider possible later hip conversion and these results when choosing the appropriate fixation implant. [203] (10.1016/j.arth.2012.04.009)
• [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. [204] (10.2106/00004623-200401000-00024)
• [L3] Hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play. [208] (10.1016/j.arth.2021.04.004)
• [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. [210] (10.1186/s12891-020-03399-8)
• [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. [211] (10.1016/j.arth.2018.12.035)
• [L4] The study suggests primary total hip replacement may be the management of choice in rheumatoid patients and for young patients unsuitable for internal fixation. [212] (10.1016/0020-1383(81)90249-7)
• [L4] The Unified Classification System (UCS) for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts. [213] (10.1302/0301-620x.96b11.34214)
• [L1] Uncemented and antibiotic-loaded cemented fixations remain options for the prevention of prosthetic joint infection in primary total hip replacement. [215] (10.3390/jcm8050722)
• [L4] Conversion of failed hip internal fixation to THA is clinically successful with an elevated risk of complications. [216] (10.1016/j.arth.2012.04.003)
• [L5] Postoperative physical therapy remains an essential component of standard care following total joint arthroplasty, but the specific approach should be individualized. [217] (10.1016/j.arth.2024.10.105)
• [Paper] Superior displacement of the hip center caused a 13% decrease in the moment arm of the abductors and a 43% decrease in their force-generating capacity. [218] (10.1002/jor.1100140212)
• [L3] Surgeons should utilize implants with an acceptable track record that allow stable fixation and restoration of hip biomechanics. [219] (10.2106/jbjs.20.01931)
• [L4] Most patients are able to return to preoperative levels of low- and moderate-impact sports between 7 and 12 months after total hip arthroplasty. [221] (10.1177/03635465211045698)
• [L5] Studies of relative motions of hip stems should be performed using dynamic loading cycles to distinguish an initial transient phase from a steady-state phase. [223] (10.1002/jor.1100140108)
• [L3] The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. [224] (10.1302/0301-620x.103b7.bjj-2020-2448.r2)
• [L4] Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans. [225] (10.1302/0301-620x.95b8.31377)
• [L4] A rapid rehabilitation protocol is safe and fulfills the potential benefits of a rapid recovery with minimally invasive total hip arthroplasty. [226] (10.1097/01.blo.0000150127.80647.80)
• [L4] Despite these reduced kinetic variables in the operated hip, the joints of the non-operated limb generated similar joint kinetics as the matched control participants. [227] (10.1002/jor.22127)
• [L3] The lumbosacral and hip motions were the major contributors to global alignment postural change. [228] (10.1186/s12891-021-04865-7)
• [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. [232] (10.1302/0301-620x.99b2.bjj-2016-0098.r1)
• [L3] The hip morphotype had a major impact on the timing of THA. [234] (10.1016/j.arth.2025.11.034)
• [Paper] Our results suggest that MIS THR contributes to a greater symmetry of hip reaction forces in absolute value as well as force-orientation following THR. [235] (10.1002/jor.22710)
• [L3] The reference values for hip ROM used in previous biomechanical reports may not reflect the actual postoperative anatomic hip ROM in patients undergoing a standard THA via the posterolateral approach. [236] (10.1016/j.arth.2007.02.004)
• [L4] The results of our model demonstrate that THA is a cost-effective option compared to non-operative management in patients 80 years old. [237] (10.1016/j.arth.2017.11.063)
• [L3] The benefits of same-day discharge total hip arthroplasty can be safely extended to the carefully indicated and motivated Medicare patient. [239] (10.1016/j.arth.2019.09.040)
• [L4] In vivo squatting kinematics suggest no danger of impingement or subsequent dislocation, but excessively large hip flexion and small cup anteversion remain as risks. [240] (10.1016/j.arth.2021.12.028)
• [L3] These data suggest that rapid discharge following total hip arthroplasty can be performed safely in select patients older than 70. [241] (10.1016/j.arth.2023.08.065)
• [L4] Slightly less hip flexion was however recorded with the inertial measurement units which may be due to the difference in the modelling of the pelvis, soft tissue artefacts, and malalignment between the two methods or misplacement of the inertial measurement units. [243] (10.1186/s12891-019-2416-4)
• [L2] There is no benefit in hip range of movement or hip function when head sizes > 36 mm are used. [247] (10.1302/2058-5241.3.170061)
• [L5] This CORR Insights commentary emphasizes the need for more high-quality, large-scale data and standardized biomechanical variables to better understand how joint loading is influenced by hip osteoarthritis and restored after total hip arthroplasty. [248] (10.1097/corr.0000000000000865)
• [L3] These data suggest that increased travel distance to treatment centers does not markedly impact outcomes following primary THA. [249] (10.1016/j.arth.2024.10.027)
• [L4] The majority of patients were able to maintain their physical activity level in the long term after primary cementless THA, compared with the activity level before the onset of restricting osteoarthritis symptoms. [250] (10.1111/sms.12482)
• [L4] Additional studies are needed to determine protective or adaptive factors in patients with abnormal anatomy who do not develop early OA and to determine whether joint preserving hip surgery extends the life of the native hip joint. [251] (10.5435/jaaos-d-16-00532)
• [L3] While same-day discharge after primary total hip arthroplasty is associated with low overall readmission rates, smoking and advanced age confer disproportionately greater readmission risk when same-day discharge is pursued. [252] (10.1016/j.arth.2026.07.054)
• [L1] In patients having unilateral total hip replacement, supervised and independent postdischarge rehabilitation did not differ for improving pain and function. [253] (10.2106/jbjs.18.00633)
• [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. [254] (10.1016/j.arth.2024.07.038)
• [L1] The literature indicates a potential role for the hip joint capsule in mechanics via mechanoreceptors, though nomenclature is inconsistent and proprioceptive roles cannot be reliably confirmed as no study has reported type I-III mechanoreceptors. [255] (10.1371/journal.pone.0229128)
• [L5] [257] (10.5435/00124635-200712000-00004)
• [L4] Total hip arthroplasty is unlikely to significantly deleteriously affect participation and performance in golf after an appropriate period of recovery, with patients having a good chance of returning to play approximately 6 months after operation. [258] (10.1016/j.arth.2006.05.030)
• [L3] Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. [259] (10.1016/j.arth.2022.12.030)
• [L2] This study supports the long-held biomechanical theory of medialisation of the acetabular component with compensatory increased femoral offset results in improved functional outcome. [261] (10.1007/s00402-016-2527-4)
• [Paper] For all the THA systems examined in this study, under the same loading conditions, a larger head leads to increasing contact areas, lower contact stresses, and higher biomechanical wear factors. [262] (10.1002/jor.24577)
• [L3] After surgery, individuals with total hip arthroplasty displayed a persistent increased contralateral shift as compared to controls, indicating the need for rehabilitation focused on normalizing loading of the limbs. [263] (10.1186/s13018-020-01663-0)
• [L4] At one year after primary THA, at least 13% of Danish patients experienced moderate to severe postsurgical pain. [266] (10.1016/j.arth.2025.09.057)
• [L4] Standard physiotherapy rehabilitation in the UK after total hip replacement is variable and appears to rarely include progressive resistance training (PRT). [269] (10.1186/1471-2474-14-91)
• [L2] With modern surgical techniques and rehabilitation protocols, patients can, on average, return to safely braking a vehicle approximately 2 weeks after right total hip arthroplasty. [271] (10.5435/jaaosglobal-d-23-00093)
• [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. [272] (10.1186/s12891-025-08607-x)
• [L5] [274] (10.1097/01.blo.0000194727.55372.04)
• [L1] We recommend such interventions to be combined with routine care soon after hip replacement. [277] (10.1186/s13018-022-03116-2)
• [L1] This randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required. [280] (10.2106/jbjs.16.00674)
• [L4] Total hip replacement provided systematic alleviation of pain and did not aggravate functional status in non-ambulatory cerebral palsy patients, offering a more satisfactory outcome than proximal femoral resection despite a non-negligible rate of complications. [281] (10.1016/j.otsr.2016.07.010)
• [L3] Patients who had undergone total hip arthroplasty have impaired long-term self-reported physical quality of life and hip functionality but they still perform physically better than untreated patients with advanced hip osteoarthritis. [283] (10.1186/1471-2474-12-222)
• [L3] The risk of developing PJI following primary total hip arthroplasty did not change in 15 years, despite improvements in other arthroplasty outcomes. [287] (10.2106/jbjs.19.00537)
• [L5] Total hip replacement is an attractive solution for non-ambulatory patients with cerebral palsy to relieve pain, but the high complication rate (35%) and risk of revision require caution and a multidisciplinary team approach. [290] (10.1016/j.otsr.2017.02.002)
• [L5] After THA, acetabular component position can be evaluated using a variety of imaging techniques. [291] (10.1016/j.arth.2026.09.026)
• [L3] The incidence of preoperative DVT in non-fracture patients was 3.1%, with 2.4% in primary THA and 9.0% in revision THA. [298] (10.1186/s13018-023-04488-9)
• [L4] Primary total hip arthroplasty with the Taperloc femoral component is associated with a low rate of aseptic loosening at a mean follow-up of twenty years. [300] (10.2106/jbjs.g.00771)
• [L4] Total hip arthroplasty in these patients had a higher rate of mechanical failure and loosening (approximately 40 per cent) than does primary hip arthroplasty. [301] (10.2106/00004623-198971090-00012)
• [L3] MRI can effectively diagnose posterior capsular disruption in patients who have undergone THA via a posterior approach. [302] (10.5435/jaaos-d-18-00655)
• [L4] MRI can accurately describe ALTR in modular femoral neck total hip arthroplasty. [305] (10.1016/j.arth.2016.03.022)
• [L4] [318] (10.2106/00004623-198567070-00011)
• [L3] [319] (10.1177/03635465241234258)
• [L4] [325] (10.2106/jbjs.j.00774)
• [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. [326] (10.2106/jbjs.16.01501)
• [L4] In this series of 309 primary THAs in patients with AS, the 20-year cumulative incidence of any revision after primary THA was 17.5%. [327] (10.1016/j.arth.2021.01.054)
• [L5] Weight-bearing imaging is a critical adjunct to traditional supine radiographs for optimizing total hip arthroplasty component position to prevent instability and early wear. [328] (10.1055/s-0039-1697935)
• [L5] [334] (10.5435/jaaos-d-25-00476)
• [L2] Results suggest to focus on preoperative function and radiological osteoarthritis to decide when THA will be most effective. [335] (10.1186/s12891-016-1070-3)
• [L3] [336] (10.1007/s00402-015-2364-x)
• [L4] [337] (10.1016/j.arth.2019.05.032)
• [L2] Patients awaiting THA and having combined high hip and reduced lumbar spine mobility can be screened for with lateral standing radiographs of the spinopelvic complex. [341] (10.1016/j.arth.2020.02.029)
• [L3] Aseptic reoperations within 1 year following primary THA resulted in an 8- to 13-fold increased risk of subsequent PJI. [343] (10.1016/j.arth.2020.02.054)
• [L4] The AI-based analyses can accurately and consistently evaluate postoperative THA radiographs. [344] (10.1016/j.arth.2026.07.013)
• [L2] Plain radiography had the highest diagnostic accuracy in the evaluation of aseptic loosening of the acetabular component. [346] (10.2106/00004623-200411000-00015)
• [L3] The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. [347] (10.1302/0301-620x.104b3.bjj-2021-0904.r1)
• [L3] Patients revised for infection had increased mortality rates compared with the general population and those undergoing primary THA or aseptic revision. [348] (10.2106/jbjs.24.01629)
• [L4] The cumulative incidence of periprosthetic femoral fracture after primary uncemented total hip arthroplasty further increased in the second decade and reached the incidence of aseptic stem loosening in the third decade, while no risk factors for the occurrence of a periprosthetic femoral fracture could be identified. [350] (10.1016/j.arth.2017.11.022)
• [L3] The one year infection rate after primary total hip replacement was in control. [355] (10.1007/s00264-011-1444-y)
• [L5] The results indicate that this new method may function as an intraoperative alternative to DXA in THA, though more research and clinical trials are necessary before clinical use. [357] (10.1186/s13018-014-0109-0)
• [L2] MARS-MRI is as suitable as standard diagnostic tools to distinguish between aseptic failure and PJI in patients with THA. [358] (10.1186/s12891-022-05560-x)
• [L3] Early aseptic revision THA is associated with significantly higher 90-day complication rates and 2-year rerevision rates compared with a control group of primary THA without revision. [359] (10.1016/j.arth.2020.11.011)
• [L3] Over half of patients had osteoporosis; however, only 15.3% of patients had a DEXA scan before THA. [362] (10.1016/j.arth.2024.10.003)
• [L3] There is no difference in revision rates for dislocation or aseptic causes between dual mobility constructs and large femoral head bearings in primary total hip arthroplasty. [364] (10.1016/j.arth.2021.05.008)
• [L2] Radiographic evidence of FAI is common in active patients with hip complaints. [365] (10.1007/s11999-010-1233-8)
• [L3] Aseptic loosening was the most common cause of reoperation following primary THA. [367] (10.1016/j.arth.2025.02.032)
• [L3] A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements. [370] (10.1186/1471-2474-15-168)
• [L3] Contemporary aseptic revision THAs in patients ≤50 years of age demonstrated a re-revision risk of approximately 1 in 4 at 20 years. [371] (10.2106/jbjs.23.01467)
• [L4] The 15-year overall survivorship was 95.3% and with the end point of aseptic loosening, the survivorship was 97.5%. [378] (10.1097/blo.0b013e3180592a79)
• [L4] [382] (10.1016/j.arth.2017.04.015)
• [L2] Previous hospital-diagnosed or community-treated infection 0 to 6 months before primary THA does not increase the risk of PJI revision. [386] (10.1016/j.arth.2023.08.032)
• [L3] PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years. [390] (10.2106/jbjs.23.01160)
• [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. [391] (10.2106/jbjs.m.01573)
• [L3] While THA patients had more severe pain preoperatively, they experienced more immediate improvements in their pain outcomes, achieved an earlier plateau in their scores, and had lower postoperative pain than TKA patients. [394] (10.1016/j.arth.2026.04.109)
• [L3] In this nationally representative multipayer study using recent data, patients who received antibiotic prophylaxis with cefazolin had lower 90-day rates of PJI compared to those receiving alternative antibiotics during primary THA. [396] (10.1016/j.arth.2025.04.079)
• [L1] Measures that reduce the risk of these complications should be considered in this high-risk population when undergoing primary THA. [397] (10.1302/0301-620x.102b6.bjj-2019-1473.r1)
• [L1] The use of antibiotic-impregnated cement lowered the infection rate by approximately 50% in primary hip arthroplasty. [398] (10.1080/17453670710015229)
• [L3] In postmenopausal women, HRT use before elective THA was associated with lower rates of periprosthetic fracture within 10 years of surgery and was not associated with increased venous thromboembolism risk. [399] (10.1016/j.arth.2024.12.020)
• [L3] Irrespective of single- or two-stage procedures, a high incidence of PJI was encountered. [401] (10.1007/s00402-019-03149-z)
• [L3] Notably, patients who had a diagnosis of sepsis within one year of THA displayed elevated rates of PJI and mortality. [403] (10.1016/j.arth.2026.07.016)
• [L3] Most patients resumed or exceeded preoperative activity, and many previously inactive patients participated in sports after THA. [404] (10.1016/j.arth.2025.11.025)
• [L3] There are greater incidences of periprosthetic joint infections and overall reoperations following early periprosthetic femur fractures compared to late fractures after total hip arthroplasty. [406] (10.1016/j.arth.2023.10.037)
• [L3] This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement. [407] (10.1302/0301-620x.96b8.31587)
• [L4] We observed a higher-than-expected rate of infection after revision of MOM THAs. [408] (10.1007/s11999-013-3157-6)
• [L4] At a minimum five-year follow-up, most patients who underwent DAA THA successfully returned to sporting activities, typically within six months postoperatively. [410] (10.1016/j.arth.2026.05.053)
• [L4] These results support the conclusion that six months following surgery, the gait of the majority (85%) of THA patients has not returned to normal. [412] (10.1016/s0736-0266(03)00151-7)
• [L2] A PJI following THA is associated with a significantly higher mortality risk than major aseptic revisions. [413] (10.1016/j.arth.2025.06.011)
• [L4] This study supports a relationship between increasing BMI and the long-term risk of PJI following contemporary primary THA. [414] (10.1016/j.arth.2024.03.033)
• [L1] On the basis of the clinical studies available, there is no evidence that bearing choice influences the risk of PJI. [415] (10.1302/0301-620x.100b2.bjj-2017-0575.r1)
• [L1] Mortality after THA PJI is high (11.0%) within three years of arthroplasty and comparable to 5-year rates of cancers, such as breast (11%) and prostate (1%) cancers. [416] (10.1016/j.arth.2025.04.036)
• [L3] Despite greater improvements on PROMs from preoperative to postoperative, patients undergoing early revisions after primary THA perceive significantly higher levels of pain and worse physical functionality at 1-year of follow-up. [419] (10.1016/j.arth.2023.07.019)
• [L1] Thirty percent of primary total hip prostheses were placed in a site contaminated with bacteria before insertion of the prosthesis, which might be indicative for the occurrence of prosthetic infection. [420] (10.1097/01.blo.0000149997.14631.0c)
• [L3] Several patient factors had strong independent associations with revision rates for PJI, although surgical factors were less important but may be more readily modifiable in practice. [423] (10.1016/j.arth.2018.01.021)
• [L3] Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup. [430] (10.1016/j.arth.2020.09.030)
• [L4] However, variable functional recovery and a relatively high complication rate, particularly with tapered stems, warrant caution, and surgeons should set realistic expectations, as not all patients achieve optimal results. [431] (10.1016/j.arth.2025.11.012)
• [L3] Patients who had prior lumbar spine surgery who underwent primary THA demonstrated equivalent improvements in PROs, but achieved lower overall postoperative scores and met hip arthroplasty thresholds at lower rates. [432] (10.1016/j.arth.2024.10.008)
• [L3] Our results suggest that maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA. [433] (10.1186/s12891-020-3093-z)
• [L4] Functional outcomes improved significantly, with the median Oxford Hip Score increasing from 8 preoperatively to 32 at follow-up. [434] (10.2106/jbjs.25.00876)
• [L3] Patients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia. [435] (10.1016/j.arth.2024.04.060)
• [L1] Short-term recovery favors limited incision over standard incision THA. [437] (10.1007/s11999-012-2717-5)

See Also

• Hip arthroscopy
• Hip osteoarthritis
• Hip resurfacing
• Greater trochanteric pain syndrome
• Periacetabular osteotomy
• Revision hip replacement

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