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Joint Replacement & Arthroplasty

Total hip arthroplasty for refractory pain and mobility loss: indications, surgical approach selection, and risk mitigation for dislocation and aseptic loosening.

Overview

Hip arthroscopy for femoroacetabular impingement with acetabular microfracture demonstrates 77% survivorship at 10-year follow-up, with significant improvement in all patient-reported outcomes among patients who did not require total hip arthroplasty conversion [1]. Conversely, hip arthroscopy in the presence of advanced osteoarthritis yields 57% survivorship at 10 years; however, in cases where total hip arthroplasty was avoided, 78% of patients considered their 10-year post-arthroscopy state satisfactory, with outcomes similar to a matched non-osteoarthritis cohort [8]. Hip preservation surgery is not designed to treat irreparable cartilage damage, though long-term survivorship is expected to improve with advancements in techniques, patient diagnosis, and surgical indications [24].

Total hip arthroplasty remains a highly successful procedure for posttraumatic arthritis, though it offers less favorable results than surgery for primary osteoarthritis [26]. This indication carries a higher incidence of intraoperative and postoperative complications, including periprosthetic fractures, infection, instability, and decreased survivorship compared to primary osteoarthritis [26]. In appropriately selected patients with sickle cell hemoglobinopathies, total hip arthroplasty provides significant pain relief, restoration of function, and patient satisfaction despite increased risks for medical and surgical complications [4]. The worldwide survival rate of total hip arthroplasties is rising [10].

Periacetabular osteotomy can provide durable benefit across a broad age range, with subsequent total hip arthroplasty demonstrating acceptable long-term survivorship following the procedure [21]. Patient selection and surgical technique are critical factors in hip resurfacing arthroplasty [12]. For patients with shorter life expectancy or those over 80 years of age, hemiarthroplasty is reasonable, whereas total hip arthroplasty offers superior functional scores and lower reoperation rates in specified populations [47]. Total elbow replacement can yield good results in carefully selected patients, particularly those with rheumatoid arthritis and pain-related disability, but carries a high complication rate requiring cautious patient selection [54]. Current perioperative treatment principles aim to decrease complications and readmissions while improving outcomes [2]. Authors advocate against the utilization of intrawound vancomycin powder in primary total hip arthroplasty until future prospective randomized studies determine its safety and efficacy conclusively [11].

Anatomy & Pathophysiology

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 [13]. The ultimate goal is to restore normal hip biomechanics with adequate sizing, position, and fixation of prosthetic components while minimizing complications [36]. Hip microinstability, characterized by abnormal femoral head micromotion within the acetabulum leading to cartilage damage and osteoarthritis, is often associated with acetabular dysplasia or femoroacetabular impingement syndrome [51].

Pathomechanics & Reconstruction: The cornerstone of treatment for the prearthritic hip is the correction of the problematic mechanical abnormality [63]. Surgeons must carefully assess pathomechanics and underlying structural abnormalities like acetabular dysplasia to avoid uncontrolled expansion of hip arthroscopy, as it should not be considered the first choice for all hip pathologies [64]. Femoroacetabular impingement abnormalities are usually bilateral and commonly associated with progression of the disease to the contralateral hip [80]. Individuals without or with mild hip osteoarthritis experienced more consistent quality of life improvements over two years following hip arthroscopy compared to those with moderate-to-severe osteoarthritis [79].

Surgical Outcomes & Approaches: Once anatomic reconstruction of the hip is achieved in neglected developmental dysplasia via total hip arthroplasty with subtrochanteric shortening osteotomy, patients have a remarkably good functional capacity and implant survival during long follow-up periods [59]. At one-year postoperatively, both anterior and posterior approaches for hip resurfacing arthroplasty restored gait patterns comparable to healthy controls [62]. There were no significant differences in kinematics, kinetics, or spatiotemporal parameters between anterior and posterior approaches for hip resurfacing arthroplasty at one-year postoperatively [62]. For experienced hip surgeons, the learning curve for avoiding early complications in hip resurfacing was short (25 cases or less), whereas the learning curve for achieving desired component positioning radiographically was much longer (75 to 100 cases or more) [70]. An attempt should be made to position the acetabular component in or near the true acetabular region in patients with Crowe Type-II congenital dysplasia of the hip [72].

Implant Mechanics & Longevity: Other surgical, implant, and patient factors should be considered when determining the mechanisms of failure of large diameter metal-on-metal hip arthroplasties [67]. The higher stress in HX-PE at a steep acetabular cup position did not result in increased wear in the present wear simulator study [77]. Dual-mobility components may be protective against dislocation compared with smaller-diameter femoral head sizes following total hip arthroplasty for hip fracture [82]. Increasing symptoms and decreased function related to degenerative hip disease may occur fifteen to twenty years after Colonna arthroplasty with concomitant femoral shortening and rotational osteotomy [73]. Hip sphericity improves with hip reconstructive surgery in patients with cerebral palsy [66]. The overall hip reconstruction obtained in the operating theatre using robotic assistance accurately correlated with the postoperative component position assessed independently using CT based 3D modelling [81].

Classification

BOSTI Hip: Provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty [49].

Vancouver: Determines the correct surgical approach for periprosthetic fractures [30]. B1 periprosthetic fractures are treated by fixation [30]. B2 periprosthetic fractures are treated by revision with a long stem [30]. B3 periprosthetic fractures are treated by complex reconstruction or prosthetic replacement [30].

Femoral Deficiency Algorithm: A classification system and algorithmic approach guide femoral reconstruction in revision total hip arthroplasty, recommending specific implant strategies based on the type of femoral deficiency [34].

Intertrochanteric Failure Classification: A proposed classification system serves as a clinical tool for femoral prosthesis selection in hip arthroplasty following failure of internal fixation in intertrochanteric femoral fractures, effectively reducing complications and enhancing hip function [37].

Other Considerations: Patients who underwent primary hip arthroscopy for femoroacetabular impingement with acetabular microfracture show 77% survivorship at 10-year follow-up [1]. Surgical options for osteonecrosis of the femoral head aim to preserve the joint if diagnosed before collapse [3]. Total hip arthroplasty is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone [5]. The success of total hip arthroplasty is rising with respect to survival rates [10]. Hip arthroplasty for an oncologic diagnosis is associated with worse outcomes and greater costs than in the general population [15]. The overall rates of complications and revisions were similar in both groups for hip resurfacing compared with 28-mm metal-on-metal total hip replacement, but the types of complications were different [25]. A predictive deep-learning model enables identification of patients with imminent risk of osteoarthritis progression resulting in arthroplasty within 3 years [29]. Wider studies are required to identify normal and pathological patterns in both hip and knee prostheses regarding dynamic 18F-NaF PET for diagnosing loosening [6]. Observed differences in knee scores between different study groups that have not been matched for various clinically relevant factors are at least as likely to represent differences in the patient populations as they are to represent differences in the operative technique or the design of the implant [60]. Except for patients with rheumatoid arthritis, the differences in perioperative complications were small between patients with inflammatory arthritis and primary osteoarthritis and between patients with different types of inflammatory arthritis [68]. Surgeons should consider the association between early revision and the type of implant, the number of total hip arthroplasties performed in very young patients, and the bearing surface when performing total hip arthroplasty in very young patients [76].

Clinical Presentation

Evaluation of pain in patients with apparently solidly fixed total hip arthroplasty components relies on a detailed history, careful examination, and plain radiographs [9]. A thorough workup of both the hip and the lumbar spine is warranted before operative intervention to avoid incorrect diagnostic or therapeutic measures in cases of sciatic neuropathy secondary to intrapelvic migration of an acetabular cup [22]. Preoperative osteoarthritis severity is a key predictor of total hip arthroplasty conversion in patients undergoing hip arthroscopy for femoroacetabular impingement, with nearly two-fifths of hips requiring THA within 10 years [42]. Patients who underwent primary hip arthroscopy for femoroacetabular impingement with acetabular microfracture showed 77% survivorship at 10-year follow-up [1]. In patients who did not require total hip arthroplasty (THA) conversion after primary hip arthroscopy for femoroacetabular impingement with acetabular microfracture, significant improvement in all patient-reported outcomes (PROs) was demonstrated [1].

Comorbidity and Risk Factors: Metabolic syndrome is associated with impaired functional and psychological outcomes after total hip arthroplasty, with dyslipidemia identified as a particularly relevant contributing component [39]. Standard comorbidity measures do not predict patient-reported outcomes 1 year after total hip arthroplasty; only knowing if the other hip is affected and whether the patient suffers from other joint pain or comorbidities affecting ambulation is needed to account for patient comorbidities [41]. Total hip arthroplasty in appropriately selected patients with sickle cell hemoglobinopathies can provide significant pain relief, restoration of function, and patient satisfaction despite increased risks for medical and surgical complications [4]. 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 [5].

Oncologic and Revision Considerations: Hip arthroplasty for an oncologic diagnosis is associated with worse outcomes and greater costs than in the general population [15]. The limited extent of radiological changes and the lack of associated symptoms do not justify the routine arthroplasty of the acetabulum in patients with a tumour using a bipolar femoral head [18]. Prevalence of radiological loosening signs and/or pain intensity follow an almost parallel course around the first revision of a total hip arthroplasty for aseptic component loosening [7]. Pseudotumour is an infrequent but important contributor to delayed instability following metal-on-polyethylene total hip arthroplasty, often overlooked in the differential diagnosis [19].

Indications and Outcomes: The absence of long-term complications after total hip arthroplasty strengthens the conclusion regarding its use for displaced femoral neck fractures compared with internal fixation [23]. Findings question whether total hip arthroplasty should be prioritized only for patients who have severe hip osteoarthritis symptoms, though confirmation in a trial is required [20].

Investigations

Plain radiography: A detailed history, careful examination, and plain radiographs provide the most useful information for evaluating pain in patients with apparently solidly fixed total hip arthroplasty components [9]. In the context of aseptic component loosening, the prevalence of radiological loosening signs and/or pain intensity follows an almost parallel course around the first revision of a total hip arthroplasty [7]. Regarding acetabular cup stability in Charnley low-friction total hip arthroplasty, the more extensive the demarcation on the initial postoperative radiograph, the greater the risk of migration of the cup [89]. This risk is particularly increased when there is a loss of the acetabular bone stock or rapid polyethylene wear [89]. Radiographic osteoarthritis was correlated with higher failure rates, increased conversion to total hip arthroplasty, and worse outcomes after surgical management of femoroacetabular impingement [83]. For patients with a tumour using a bipolar femoral head after prosthetic arthroplasty of the proximal femur, the limited extent of radiological changes and the lack of associated symptoms do not justify the routine arthroplasty of the acetabulum [18]. Revision of a stable component is not justifiable on the basis of its long duration in use, non-ideal position, or possible loosening on radiographs [31]. Primary total hip replacement with insertion of an acetabular component without cement and a femoral component with cement showed excellent clinical results at intermediate follow-up with few hips showing progressive radiolucent lines [96].

CT: Parameters derived from cross-sectional CT imaging can be useful additional preoperative planning tools for total hip arthroplasty [78].

Other Considerations: Patients who underwent primary hip arthroscopy for femoroacetabular impingement with acetabular microfracture showed 77% survivorship at 10-year follow-up [1]. In patients who did not require total hip arthroplasty conversion after primary hip arthroscopy for femoroacetabular impingement with acetabular microfracture, significant improvement in all patient-reported outcomes was demonstrated [1]. There is no consensus on a particular treatment for osteonecrosis of the femoral head [3]. Surgical options for osteonecrosis of the femoral head aim to preserve the joint if diagnosed before collapse [3]. A predictive deep-learning model based on radiographs enables identification of patients with imminent risk of osteoarthritis progression resulting in arthroplasty within 3 years [29]. Reoperations may not be directly linked to radiographic and functional outcomes but are important from the patient's perspective and in terms of cost-effectiveness for developmental dysplasia of the hip treated at walking age [92]. Revision of previously cemented hip arthroplasties with uncemented modular femoral components yielded good mid-term clinical and radiological results [97]. Wider studies are required to identify normal and pathological patterns in both hip and knee prostheses using dynamic 18F-NaF PET for diagnosing and distinguishing between septic and aseptic loosening [6]. Pseudotumour is an infrequent but important contributor to delayed instability following metal-on-polyethylene total hip arthroplasty, often overlooked in the differential diagnosis [19]. A thorough workup of both the hip and the lumbar spine is warranted before operative intervention for sciatic neuropathy secondary to intrapelvic migration of an acetabular cup to avoid incorrect diagnostic or therapeutic measures [22]. The size of the cup affects the anterior capsular distance in total hip arthroplasty as measured with ultrasound [94]. This factor should be considered when evaluating sonography of the anterior capsular distance after total hip arthroplasty [94].

Treatment

Non-Operative

Evidence regarding non-operative management for femoroacetabular impingement and osteoarthritis is limited within the provided dataset, which primarily focuses on surgical outcomes and conversion rates.

Operative

Indications: Hip arthroscopy is indicated for young patients with early or midstage arthritis of the hip joint [17], whereas it is not designed to treat irreparable cartilage damage [24]. For osteonecrosis of the femoral head, surgical options aim to preserve the joint if diagnosed before collapse [3]. Total hip arthroplasty (THA) is increasingly offered for osteoarthritis in patients with fragile or pathologic bone [5] and remains a reliable intervention for end-stage hip disease [14]. In patients with sickle cell hemoglobinopathies, THA can provide significant pain relief and functional restoration despite increased medical and surgical risks [4]. Metal-on-metal hip resurfacing should be approached with caution and used only in patients who meet all recommended selection criteria [38].

Surgical Approach / Technique: Total hip arthroplasty for developmental dysplasia of the hip is technically demanding, requiring an in-depth understanding of anatomical abnormalities and complex techniques [13]. The correct approach for periprosthetic fractures depends on the Vancouver classification [30]. Vancouver B1 periprosthetic fractures are treated by fixation [30], while Vancouver B2 fractures are treated by revision with a long stem [30]. Vancouver B3 fractures are treated by complex reconstruction or prosthetic replacement [30]. In the setting of severe femoral bone loss, removal of a trabecular metal osteonecrosis intervention implant and conversion to primary THA is a simple, fast technique that should be considered a viable option to reduce surgical and medical morbidity [32]. Advances in blood loss and pain management protocols associated with the direct anterior approach should renew interest in the efficacy of one-stage bilateral total hip arthroplasty [33].

Implant Selection: A straight-stemmed, plasma-sprayed, titanium-alloy, uncemented femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty [44]. Porous-coated implants can provide stable fixation without the use of cement in primary total hip reconstruction [52], and cementless components had more durable fixation than cemented components in primary total hip arthroplasty [53]. Fixation of porous-coated acetabular components with screw fixation was uniformly excellent with no loosening at a mean of seven years [46]. Revision of the acetabular component without cement after total hip arthroplasty showed no increase in the rate of aseptic loosening at seven to eleven years [16]. Authors consider revision of the acetabular component without cement to be a good option for revisions of such components [16]. Findings support the use of a structural allograft in the presence of massive loss of bone to achieve the goals of a revision hip replacement [35]. The survivorship of proximal femoral replacement in contemporary revision total hip arthroplasty for severe femoral bone loss is good at five years [45]. Results in hip arthroplasty with an inert prosthesis are very encouraging for non-union, traumatic necrosis, and osteoarthritis [69].

Alignment / Balancing Strategy: Patient selection and surgical technique are important in hip resurfacing arthroplasty [12].

Pain Management: Duloxetine can be part of a multimodal management regimen in patients with total hip arthroplasty and total knee arthroplasty [93]. Limiting or eliminating opioids for preoperative pain management could reduce the overall cost of care in the era of bundled payments for total joint arthroplasty [88]. In total hip arthroplasty patients, the direct anterior approach was associated with early functional recovery and less pain scores compared with the posterior approach [86].

Adjuncts: Authors advocate against the utilization of intrawound vancomycin powder in primary total hip arthroplasty until future prospective randomized studies determine its safety and efficacy conclusively [11].

Setting of Care: Following perioperative treatment principles can result in decreased perioperative complications, readmissions, and improved outcomes in total hip and total knee arthroplasty [2].

Revision: Revision of a stable component is not justifiable on the basis of its long duration in use, non-ideal position, or possible loosening on radiographs [31]. Modular component exchange for treatment of recurrent dislocation of a total hip replacement should be considered because it avoids the morbidity associated with revision of well-fixed components [48]. Late dislocation after total hip arthroplasty is more common than was previously thought and can result from long-standing prosthesis problems, new problems, or a combination of factors [50]. Dislocation continues to be the most common complication of proximal femoral replacement in contemporary revision total hip arthroplasty for severe femoral bone loss [45].

Other Considerations: There is no consensus on a particular treatment for osteonecrosis of the femoral head [3]. Future therapies for osteonecrosis of the femoral head include biologically active molecules and implants [3]. Hip arthroscopy in the presence of advanced osteoarthritis results in 57% survivorship at 10 years [8]. In patients where total hip arthroplasty was avoided after hip arthroscopy for advanced osteoarthritis, 78% considered their 10-year post-hip arthroscopy state to be satisfactory [8]. Patient-reported outcomes for hip arthroscopy in advanced osteoarthritis were similar to a matched non-osteoarthritis cohort where total hip arthroplasty was avoided [8]. Long-term survivorship of hip preservation surgery is expected to improve with advancements in techniques, patient diagnosis, and surgical indications [24]. The long-term effect of the elevated-rim acetabular liner on wear and loosening remains unknown [55]. Routine use of the elevated-rim acetabular liner is not currently advocated [55]. Twenty percent of patients undergoing hip arthroplasty with an inert prosthesis are not improved or suffer recurrence of pain [69]. Anesthetic technique differences were associated with patient and provider characteristics in primary total hip arthroplasties [85]. Findings question whether total hip arthroplasty should be prioritized only for patients with severe hip osteoarthritis symptoms, though confirmation in a trial is required [20]. A detailed history, careful examination, and plain radiographs provide the most useful information for evaluating pain in patients with apparently solidly fixed total hip arthroplasty components [9].

Complications

Infection (PJI): Patients receiving cefazolin prophylaxis during primary total hip arthroplasty demonstrate lower 90-day periprosthetic joint infection (PJI) rates compared to those receiving alternative antibiotics [91]. The proportion of infection as a cause for reoperation has increased over time, paralleling a decrease in aseptic loosening [75]. Revision surgery performed specifically for infection is associated with increased mortality rates relative to the general population and patients undergoing primary arthroplasty or aseptic revision [74]. In the specific context of conversion total hip arthroplasty following failed femoral neck fractures, the single-stage revision technique may be associated with a lower incidence of PJI [109].

Aseptic loosening: Radiological signs of loosening and pain intensity follow an almost parallel course around the first revision of a total hip arthroplasty for aseptic component loosening [7]. While aseptic loosening remains a primary indication for revision, its proportion as a cause for reoperation has decreased with time [75].

Instability: Total hip arthroplasty for posttraumatic arthritis yields less favorable results than surgery for primary osteoarthritis, characterized by a higher incidence of instability [26]. Dislocation rates are significantly higher following salvage total hip arthroplasty compared to primary total hip arthroplasty [90].

Periprosthetic fracture: Female gender, rheumatoid arthritis, and revision arthroplasty constitute major risk factors for periprosthetic fractures after hip arthroplasty [103]. The proportion of periprosthetic fracture (PPF) as a cause for reoperation has increased over time [75]. Total hip arthroplasty for posttraumatic arthritis carries a higher incidence of intraoperative and postoperative periprosthetic fractures compared to primary osteoarthritis surgery [26]. Resurfacing arthroplasty is associated with a higher early complication rate than total hip arthroplasty, which includes fracture risk [107]. Conversion of a failed hemiarthroplasty to total hip arthroplasty remains a high-risk procedure for subsequent complications, including fracture [104].

Thromboembolism: Revision total hip arthroplasty alone is not an independent risk factor for deep vein thrombosis (DVT) and pulmonary embolism (PE) when compared to primary hip arthroplasty [84].

Other Considerations: Adherence to perioperative treatment principles results in decreased perioperative complications, readmissions, and improved outcomes [2]. Total hip arthroplasty in patients with sickle cell hemoglobinopathies carries increased risks for both medical and surgical complications [4]. Patients treated by arthroplasty-trained surgeons for elective total hip arthroplasty experience fewer complications up to two years postoperatively [28]. The incidence of medical complications is highest in nonagenarian patients undergoing hip and knee arthroplasty, though orthopaedic complication rates remain similar [106]. Total hip arthroplasty for posttraumatic arthritis offers less favorable results than primary osteoarthritis surgery, with a higher incidence of periprosthetic fractures, infection, instability, and decreased survivorship [26]. Dislocation, reoperation, and revision rates after salvage total hip arthroplasty were higher than those after primary total hip arthroplasty [90].

Recovery

Light activity (weeks): Patients undergoing primary hip arthroscopy for femoroacetabular impingement with acetabular microfracture demonstrate significant improvement in patient-reported outcomes, with 78% of those avoiding total hip arthroplasty (THA) conversion considering their 10-year post-arthroscopy state satisfactory [1, 8]. For young patients with early or midstage arthritis, arthroscopic treatment remains an acceptable option to facilitate a return to daily activities [17]. In cases of failed metal-on-metal resurfacing arthroplasty (MMRA), conversion to THA presents safety and surgical effort profiles similar to primary THA, supporting early mobilization protocols [27].

Full activity (months): Short and mid-term efficacy of biologic hip resurfacing (BHR) in young osteoarthritis patients indicates a swift return to work and physical activities, alongside good implant survival and functional improvement [58]. Total knee arthroplasty in patients with Parkinson's disease achieves very good functional results through predetermined intraoperative protocols and aggressive postoperative physical therapy regimens [56]. Autologous matrix-induced chondrogenesis for hip cartilage repair enhances the potential for patients to resume recreational athletic activities, showing significant clinical improvement over pre-operative evaluations at 2 years [108].

Complete recovery / outcome plateau (months): Ceramic-on-ceramic (CoC) bearings for total hip arthroplasty demonstrate high survivorship and excellent functional outcomes for at least 10 years [102]. Hybrid primary total hip arthroplasty (femoral component with cement and acetabular component without cement) results in very good clinical function at ten to thirteen years, though the rate of dislocation remains high during this period [105]. Prevalence of radiological loosening signs and pain intensity in revision THA for aseptic component loosening follow an almost parallel course around the first revision [7]. Total hip arthroplasty in appropriately selected patients with sickle cell hemoglobinopathies provides significant pain relief and restoration of function despite increased medical and surgical risks [4].

Rehabilitation protocol: Following perioperative treatment principles results in decreased perioperative complications, readmissions, and improved outcomes in total hip and total knee arthroplasty [2]. Patients undergoing elective total hip arthroplasty with arthroplasty-trained surgeons experience fewer complications up to two years postoperatively [28]. Total hip arthroplasty remains a reliable intervention for end-stage hip disease due to improved risk stratification, perioperative protocols, and rapid-recovery pathways [14].

Functional milestones: In patients who did not require THA conversion after primary hip arthroscopy for femoroacetabular impingement with acetabular microfracture, significant improvement in all patient-reported outcomes (PROS) was demonstrated [1]. Patient-reported outcomes in patients with advanced osteoarthritis undergoing hip arthroscopy where THA was avoided were similar to a matched non-osteoarthritis cohort [8]. Hip resurfacing arthroplasty in inflammatory arthritis yielded good to excellent clinical outcomes in 30 of 31 hips at a minimum follow-up of 3 years [110].

Other Considerations: Total hip arthroplasty is increasingly offered for osteoarthritis of the hip in patients with fragile or pathologic bone, supported by early literature demonstrating improved functional and patient-reported outcome scores [5]. Periacetabular osteotomy (PAO) provides durable benefit across a broad age range, with subsequent total hip arthroplasty performing with acceptable long-term survivorship [21]. With increased surgeon experience, fewer conversions to total hip arthroplasty were seen in segmental labral reconstructions, and revision rates and patient-reported outcomes were similar between the first 100 and most recent 100 patients [57].

Key Evidence

  • [L4] Further, in the patients that did not require THA conversion, significant improvement in all PROS was demonstrated. (10.1016/j.arthro.2022.11.018)
  • [L5] The goal of this symposium is to provide the everyday arthroplasty surgeon with current opinions on perioperative treatment, and following these principles should result in decreased perioperative complications, readmissions, and improved outcomes. (10.1016/j.arth.2018.07.009)
  • [L5] There is no consensus yet on a particular treatment, with surgical options aiming to preserve the joint if diagnosed before collapse, while future therapies include biologically active molecules and implants. (10.1302/2058-5241.4.180036)
  • [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. (10.5435/00124635-200505000-00007)
  • [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. (10.2106/jbjs.20.01398)
  • [L2] Wider studies are required to identify normal and pathological patterns in both hip and knee prostheses. (10.1186/s13018-014-0147-7)
  • [L3] Prevalence of radiological loosening signs and/or pain intensity follow an almost parallel course around the first revision of a THA for aseptic component loosening. (10.1186/1471-2474-14-167)
  • [L4] Where THA was avoided, 78% considered their 10-year post-HA state to be satisfactory, with patient-reported outcomes similar to a matched non-OA cohort. (10.1016/j.arthro.2022.07.022)
  • [L5] A detailed history, careful examination, and plain radiographs provide the most useful information for evaluating pain in patients with apparently solidly fixed total hip arthroplasty components. (10.5435/00124635-200203000-00004)
  • [L2] We believe that it is safe to state that the success of THA is still rising with respect to this main outcome. (10.1530/eor-23-0080)
  • [L3] Until future prospective randomized studies determine the safety and efficacy of IVP in THA conclusively, the authors advocate against its utilization. (10.1016/j.arth.2024.03.063)
  • [L4] This report highlights the importance of patient selection and surgical technique in hip resurfacing arthroplasty. (10.2106/jbjs.i.00341)
  • [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. (10.1186/s42836-019-0004-6)
  • [L3] Hip arthroplasty for an oncologic diagnosis is associated with worse outcomes and greater costs than in the general population, and Comprehensive Care for Joint Replacement should incorporate risk adjustment for oncologic disease. (10.1016/j.arth.2020.01.017)
  • [L3] There was no increase in the rate of aseptic loosening, and the authors consider this approach to be a good option for revisions of such components. (10.2106/00004623-199609000-00011)
  • [L4] The presented approach is an acceptable treatment option for young patients with early or midstage arthritis of the hip joint. (10.1007/s00167-005-0009-2)
  • [L4] The limited extent of these changes and the lack of associated symptoms do not justify the routine arthroplasty of the acetabulum in these patients. (10.1302/0301-620x.97b12.36366)
  • [L4] Pseudotumour is an infrequent but important contributor to delayed instability following metal-on-polyethylene total hip arthroplasty, often overlooked in the differential diagnosis. (10.1302/0301-620x.98b2.36593)
  • [L3] These findings question whether THA should be prioritized only for those patients who have severe hip OA symptoms, but require confirmation in a trial. (10.1016/j.arth.2025.04.032)
  • [L4] PAO can provide durable benefit across a broad age range, and subsequent THA can be performed with acceptable long-term survivorship. (10.1016/j.arth.2026.01.056)
  • [Case_report] A thorough workup of both the hip and the lumbar spine is warranted before operative intervention to avoid incorrect diagnostic or therapeutic measures. (10.2106/00004623-199709000-00015)
  • [L2] The absence of long-term complications after total hip arthroplasty strengthens this conclusion. (10.2106/jbjs.k.00244)
  • [Commentary] Hip preservation surgery is not designed to treat irreparable cartilage damage, and long-term survivorship is expected to improve with advancements in techniques, patient diagnosis, and surgical indications. (10.1016/j.arthro.2021.03.027)
  • [L1] The overall rates of complications and revisions were similar in both groups but were of different types. (10.2106/jbjs.20.00030)
  • [L5] Total hip arthroplasty for posttraumatic arthritis is a highly successful procedure but offers less favorable results than surgery for primary osteoarthritis, with a higher incidence of intraoperative and postoperative complications including periprosthetic fractures, infection, instability, and decreased survivorship. (10.5435/jaaos-d-17-00775)
  • [L4] Conversion of failed MMRA is similar to a primary THA in terms of safety, surgical effort, and early clinical results. (10.1016/j.arth.2008.01.276)
  • [L3] Patients who underwent elective THA with arthroplasty-trained surgeons experienced fewer complications up to two years postoperatively. (10.1016/j.arth.2025.09.045)
  • [L4] The model enables identification of patients with imminent risk of osteoarthritis progression resulting in arthroplasty within 3 years. (10.2106/jbjs.23.01317)
  • [L5] The correct approach depends on the Vancouver classification, with B1 fractures treated by fixation, B2 by revision with a long stem, and B3 by complex reconstruction or prosthetic replacement. (10.1302/0301-620x.96b11.34300)
  • [L4] This simple, fast technique should be considered a viable option during conversion THA to reduce surgical and medical morbidity. (10.1016/j.arth.2012.01.025)
  • [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. (10.2106/00004623-200300004-00001)
  • [L3] The findings support the use of a structural allograft in the presence of massive loss of bone to achieve the goals of a revision hip replacement. (10.2106/00004623-199605000-00008)
  • [L3] The proposed classification system serves as an innovative clinical tool for femoral prosthesis selection in hip arthroplasty post-FIF-ITF, effectively reducing complications and enhancing hip function in the Classification-based Decision Group, underscoring its significant clinical utility. (10.1186/s13018-024-05136-6)
  • [L4] Metal-on-metal hip resurfacing should be approached with caution and used only in patients who meet all recommended selection criteria. (10.1302/2058-5241.1.160014)
  • [L3] Metabolic syndrome is associated with impaired functional and psychological outcomes after total hip arthroplasty, with dyslipidemia identified as a particularly relevant contributing component. (10.1016/j.arth.2026.04.006)
  • [L5] Only knowing if the other hip is affected and whether the patient suffers from other joint pain or comorbidities affecting ambulation is needed to account for patient comorbidities. (10.1007/s11999-015-4252-7)
  • [L4] However, preoperative OA severity is a key predictor of THA conversion with nearly two‐fifths of hips requiring THA within 10 years. (10.1002/ksa.12709)
  • [L4] This femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty. (10.2106/00004623-200401000-00014)
  • [L4] While the survivorship of the implant is good at five years, dislocation continues to be the most common complication. (10.1302/0301-620x.99b3.bjj-2016-0822.r1)
  • [L3] At a mean of seven years, fixation of this porous-coated component was uniformly excellent with no loosening. (10.2106/00004623-199607000-00001)
  • [L1] While HA is reasonable for patients with shorter life expectancy or over 80 years, THA offers superior functional scores and lower reoperation rates in the specified populations. (10.1016/j.arth.2019.08.061)
  • [L4] This method should be considered because it avoids the morbidity associated with revision of well-fixed components. (10.2106/00004623-200110000-00011)
  • [L2] The proposed BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during THA. (10.1302/0301-620x.106b9.bjj-2024-0529.r1)
  • [L3] Late dislocation is more common than was previously thought and can result from long-standing prosthesis problems, new problems, or a combination of factors. (10.2106/00004623-200211000-00007)
  • [L3] The results indicate that porous-coated implants can provide stable fixation without the use of cement. (10.2106/00004623-199304000-00010)
  • [L3] Cementless components had more durable fixation than cemented components. (10.1016/j.arth.2007.11.010)
  • [L3] However, the long-term effect on wear and loosening remains unknown, and routine use is not currently advocated. (10.2106/00004623-199601000-00011)
  • [L4] Total knee arthroplasty in patients with Parkinson's disease achieved very good functional results through a predetermined intraoperative protocol and an aggressive postoperative physical therapy regimen. (10.1016/j.arth.2008.01.267)
  • [L4] With increased surgeon experience, fewer conversions to total hip arthroplasty were seen; however, revision rates and patient-reported outcomes were similar between the first 100 and most recent 100 patients. (10.1007/s00167-019-05692-z)
  • [L3] Our data support the short and mid-term efficacy of BHR arthroplasty in young OA patients, indicating good implant survival, improvement in patients' functionality and a swift return to work and physical activities after surgery. (10.1186/s12891-019-2498-z)
  • [L5] Although a demanding technique with a high rate of related complications, once anatomic reconstruction of the hip is achieved, patients have a remarkably good functional capacity and implant survival during long follow-up periods. (10.1302/2058-5241.1.000026)
  • [L4] Observed differences in knee scores between different study groups that have not been matched for various clinically relevant factors are at least as likely to represent differences in the patient populations as they are to represent differences in the operative technique or the design of the implant. (10.2106/00004623-199706000-00009)
  • [L3] At one-year postoperatively, both approaches restored gait patterns comparable to healthy controls, with no significant differences in kinematics, kinetics, or spatiotemporal parameters. (10.1186/s13018-025-06457-w)
  • [L5] The cornerstone of treatment of the prearthritic hip is the correction of the problematic mechanical abnormality. (10.2106/jbjs.20.01494)
  • [L5] Hip arthroscopy should not be considered the first choice for all hip pathologies; surgeons must carefully assess pathomechanics and underlying structural abnormalities like acetabular dysplasia to avoid uncontrolled expansion of the procedure. (10.1016/j.arthro.2007.03.007)
  • [L4] Hip sphericity improves with hip reconstructive surgery. (10.1302/0301-620x.103b1.bjj-2020-1339.r1)
  • [L3] Other surgical, implant and patient factors should be considered when determining the mechanisms of failure of large diameter metal-on-metal hip arthroplasties. (10.1302/0301-620x.98b7.36554)
  • [L3] Except for patients with RA, the differences in perioperative complications was small between patients with IA and primary OA and between patients with different types of IA. (10.1186/s12891-022-05891-9)
  • [L4] Results in hip arthroplasty with an inert prosthesis are very encouraging for non-union, traumatic necrosis, and osteoarthritis, though 20% of patients are not improved or suffer recurrence of pain. (10.1007/s11999-008-0572-1)
  • [L2] For experienced hip surgeons, the learning curve for avoiding early complications was short (25 cases or less), while the learning curve for achieving desired component positioning radiographically was much longer (75 to 100 cases or more). (10.1007/s11999-009-1106-1)
  • [L3] An attempt should be made to position the acetabular component in or near the true acetabular region. (10.2106/00004623-199607000-00004)
  • [L4] However, increasing symptoms and decreased function related to degenerative hip disease may occur fifteen to twenty years after the procedure. (10.2106/00004623-199701000-00009)
  • [L3] Patients revised for infection had increased mortality rates compared with the general population and those undergoing primary THA or aseptic revision. (10.2106/jbjs.24.01629)
  • [L3] However, the proportion of infection and PPF increased as a cause of reoperations, while the proportion of aseptic loosening decreased with time. (10.1016/j.arth.2025.02.032)
  • [L3] Surgeons should consider the association between early revision and the type of implant, the number of THAs performed in these patients, and the bearing surface when performing THA in very young patients. (10.1302/0301-620x.100b10.bjj-2017-1441.r2)
  • [L3] Our study suggests that parameters derived from cross-sectional CT imaging can be useful additional preoperative planning tool for THA. (10.1186/s12891-017-1926-1)
  • [L3] Individuals without or with mild hip osteoarthritis experienced more consistent QoL improvements over two years compared to those with moderate-to-severe osteoarthritis. (10.1016/j.jisako.2025.101044)
  • [L4] Femoroacetabular impingement abnormalities are usually bilateral and are commonly associated with progression of the disease to the contralateral hip. (10.2106/jbjs.j.01734)
  • [L4] The overall hip reconstruction obtained in the operating theatre using robotic assistance accurately correlated with the postoperative component position assessed independently using CT based 3D modelling. (10.1302/0301-620x.100b10-bjj-2018-0201.r1)
  • [L3] Dual-mobility components may be protective against dislocation compared with smaller-diameter femoral head sizes. (10.1302/0301-620x.107b10.bjj-2024-1637.r1)
  • [L1] Radiographic osteoarthritis was correlated with higher failure rates, increased conversion to total hip arthroplasty, and worse outcomes after surgical management of femoroacetabular impingement. (10.5435/jaaos-d-17-00380)
  • [L3] Revision THA alone is not an independent risk factor for DVT and PE when compared to primary hip arthroplasty. (10.1016/j.arth.2017.07.028)
  • [L3] Anesthetic technique differences were associated with patient and provider characteristics. (10.1016/j.arth.2015.08.031)
  • [L1] In THA patients, compared with PA, DAA was associated with an early functional recovery and less pain scores. (10.1186/s13018-018-0929-4)
  • [L3] Limiting or eliminating opioids for preoperative pain management could reduce the overall cost of care in the era of bundled payments. (10.5435/jaaos-d-20-00316)
  • [L3] The more extensive the demarcation on the initial postoperative radiograph, the greater the risk of migration of the cup, particularly when there is a loss of the acetabular bone stock or rapid polyethylene wear. (10.2106/00004623-199709000-00012)
  • [L3] The dislocation, reoperation, and revision rates after salvage THA were higher than those after primary THA. (10.1186/s13018-023-03519-9)
  • [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. (10.1016/j.arth.2025.04.079)
  • [L3] Reoperations may not be directly linked to radiographic and functional outcomes but are important from the patient's perspective and in terms of cost-effectiveness. (10.2106/jbjs.24.00486)
  • [L1] Duloxetine can be part of a multimodal management regimen in patients with THA and TKA. (10.1186/s13018-024-04648-5)
  • [L3] This factor should be considered when evaluating sonography of the anterior capsular distance after THA. (10.1186/1471-2474-15-23)
  • [L3] The clinical results were excellent at intermediate follow-up with few hips showing progressive radiolucent lines, leading the authors to be optimistic about satisfactory long-term results. (10.2106/00004623-199605000-00009)
  • [L4] Revision of previously cemented hip arthroplasties with uncemented modular femoral components yielded good mid-term clinical and radiological results. (10.1186/s13018-015-0266-9)
  • [L3] This CoC bearing for THA had a high survivorship and excellent functional outcomes for at least 10 years. (10.1016/j.arth.2022.12.009)
  • [L1] This meta-analysis suggested that female gender, rheumatoid arthritis, and revision arthroplasty are major risk factors for the development of periprosthetic fractures after hip arthroplasty. (10.1186/s13018-020-02152-0)
  • [L3] The cumulative incidence estimate provides a more accurate estimate of revision risk compared to the Kaplan-Meier method. (10.1016/j.arth.2019.04.042)
  • [L3] The hybrid primary total hip arthroplasty resulted in very good clinical function at ten to thirteen years, although the rate of dislocation was high. (10.2106/00004623-199712000-00008)
  • [L3] The incidence of medical complications was highest in nonagenarians, but rates of orthopaedic complications were similar. (10.5435/jaaos-d-22-00406)
  • [L2] Resurfacing arthroplasty is associated with a higher early complication rate than total hip arthroplasty. (10.1016/j.arth.2008.01.235)
  • [L4] This intervention enhanced the potential for patients to resume recreational athletic activities and the 2-year clinical outcome showed significant improvement over the pre-operative evaluations. (10.1007/s00167-019-05801-y)
  • [L3] The single-stage revision technique is potentially associated with a lower incidence of periprosthetic joint infection (PJI) in conversion total hip arthroplasty after failed femoral neck fractures. (10.1186/s42836-025-00364-5)
  • [L4] The procedure yielded good to excellent clinical outcomes in 30 of 31 hips at a minimum follow-up of 3 years. (10.1016/j.arth.2011.02.016)

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Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.