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Primary Arthroplasty

Primary total hip arthroplasty for end-stage disease: selection of bearing surfaces, surgical approaches, and cemented vs uncemented fixation based on bone quality and patient age.

Overview

Contemporary, subspecialty-focused primary total hip arthroplasty (THA) allows for accurate determination of etiologies and rates of failure [1]. Demographic, clinical, surgical, implant, and provider variables are associated with the risk of revision following primary THA [2]. Primary arthroplasty may be preferred for elderly femoral neck fractures (Garden-I and II) with a degree of posterior tilt above a certain threshold [3]. Younger patients may be better candidates for joint-sparing procedures or arthroplasty with modern implants and techniques for femoral neck fracture nonunion [15].

Primary total hip arthroplasty achieves minimal clinically important difference significantly faster than revision total hip arthroplasty across multiple patient-reported outcome measures [10]. For carefully selected patients, outpatient THA might be a feasible alternative to traditional inpatient THA without compromising 1-year outcomes compared with rapid discharge [21]. Enhanced recovery after surgery protocols can be associated with decreased length of stay even in the absence of neuraxial anesthesia in some surgical settings [19].

Patients undergoing primary joint arthroplasty of the hip and knee demonstrate significant ethnic and sex differences regarding expectations and knowledge of the intervention [6]. These ethnic and sex differences in expectations and knowledge play a major role in the use and outcome of joint arthroplasty cases [6]. Surgeons should use rigorous selection criteria and counsel patients appropriately regarding the potential for subsequent need for THA in patients aged 50 years or older undergoing hip arthroscopy [4].

Anatomy & Pathophysiology

Osseous and Implant Geometry

The lineage of hip arthroplasty device predicates reflects a complex ancestral web of equivalency across a wide range of implants, although their material and design properties may be different [24]. A mismatch exists between the proximal femoral anatomy of a relevant proportion of adult hips and the implant geometry of the most common femoral component in total hip arthroplasty [54]. 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 [60]. Restoration of the normal hip center of rotation provides good long-term results and allows restoration of leg length and lever arm [65]. However, a higher hip center gained more bone coverage but decreased the range of hip flexion and internal rotation [61].

Biomechanics and Stability

The ultimate goal of total hip arthroplasty is to restore normal hip biomechanics with adequate sizing, position, and fixation of prosthetic components while minimizing complications [30]. Hip microinstability is a condition characterized by abnormal femoral head micromotion within the acetabulum, leading to cartilage damage and osteoarthritis, often associated with acetabular dysplasia or femoroacetabular impingement syndrome [44]. Robot-assisted total hip arthroplasty (R-THA) improves surgical accuracy without increasing surgical trauma, contributing to the restoration of the patient's original hip biomechanics compared to manual THA [51]. The anterior-posterior component of the hip contact load has a significant effect on the axial motion of the stem relative to the bone [53]. Factors potentially associated with the quality of bone bed and biomechanics of the hip might influence the risk of aseptic loosening in the cup of ABG I hip arthroplasty [45]. The position of the acetabular component can influence the femoral head penetration of modern highly cross-linked polyethylene (HXLPE) [48].

Patient Factors and Failure Mechanisms

Significantly increased spinal sagittal imbalance with altered pelvic mechanics is a potential cause for the reported increased risk of total hip arthroplasty dislocations in obese patients [64]. Other surgical, implant, and patient factors should be considered when determining the mechanisms of failure of large diameter metal-on-metal hip arthroplasties [63]. Patients with preoperative acetabular morphological risk factors for dislocation might be better candidates for total hip arthroplasty than hemiarthroplasty [67].

Classification

Primary THA Etiology and Risk Stratification: Primary total hip arthroplasty (THA) etiologies and failure rates are accurately determined by focusing on procedures initially performed by a contemporary, subspecialty practice [1]. Demographic, clinical, surgical, implant, and provider variables are associated with the risk of revision following primary THA [2].

Fracture Classification: Primary arthroplasty may be preferred for elderly femoral neck fractures (Garden-I and II) with a degree of posterior tilt above a certain threshold [3].

Age-Based Phenotypes: The incidence of shoulder arthroplasty in patients less than 50 years old is higher than previously reported, with most cases performed for primary osteoarthritis [7].

Approach and Navigation: The posterior approach continues to be used as the main approach for primary total hip arthroplasty [12]. Imageless navigation for primary THA does not reduce 90-day adverse events or five-year revisions in a large national cohort [8].

Implant Lineage: The lineage of hip arthroplasty device predicates reflects a complex ancestral web of equivalency across a wide range of implants, although their material and design properties may be different [24].

Stem Length Classification: A classification system for the length of femoral stems is suggested to better organize the discussion on stem length [87].

Resurfacing vs. THA Comparison: Overall rates of complications and revisions were similar in hip resurfacing compared with 28-mm metal-on-metal total hip replacement, but the types of complications differed [90].

Other Considerations: Inflammatory Arthritis: Except for patients with rheumatoid arthritis, differences in perioperative complications were small between patients with inflammatory arthritis and primary osteoarthritis, and between patients with different types of inflammatory arthritis [86]. Regionalization and Volume: Between 1991 and 2005, primary and revision THA use increased substantially, but there was minimal evidence that regionalization of THA is occurring as the percentage of procedures performed in high-volume hospitals remained relatively stable [27]. Hospital variation in revision rates after primary knee arthroplasty was not explained by patient selection, as patient-reported outcome measures prior to surgery were comparable across hospitals with differing revision rates [9]. Primary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission [99]. Conversion total hip arthroplasty requires more resources than primary THAs, as well as advanced revision type components [74].

Clinical Presentation

Etiologies and Demographics: Primary total hip arthroplasty (THA) addresses primary osteoarthritis, advanced symptomatic arthritis secondary to osteochondrodysplasia, and fragile or pathologic bone conditions [7, 17, 18]. Shoulder arthroplasty incidence in patients under 50 years is higher than previously reported, with most cases indicated for primary osteoarthritis [7]. Patient populations exhibit significant ethnic and sex differences regarding expectations and knowledge of the intervention [6]. Over a 13-year period, obesity, medical comorbidity, and psychological comorbidity increased in primary THA patients, while the diagnosis of rheumatoid or inflammatory arthritis decreased rapidly [43].

Comorbidities and Risk Factors: A preoperative mental health diagnosis negatively influences primary THA outcomes, leading to lower improvement and higher worsening rates [31]. Preoperative stroke in primary shoulder arthroplasty associates with higher perioperative complications and mortality compared to matched cohorts [37]. Hypogonadism elevates the risk of postoperative complications and care costs following primary THA [40]. Joint aspiration serves as the key diagnostic tool for Cutibacterium avidum prosthetic hip infection, with risk factors including obesity, primary hip arthroplasty, and anterior surgical approach [5].

Prognostic Indicators by Indication: Outcomes for arthroplasty following urgent or emergent femoral neck fractures are inferior to those for arthritis diagnoses [38]. The prognosis for total hip arthroplasty after acetabular fracture is less favorable than for primary degenerative arthritis [52]. Instability remains a common and devastating complication with multifactorial causes [50].

Investigations

Aspiration: Joint aspiration is the key diagnostic tool for prosthetic hip infection [5].

Plain radiography: Immediate postoperative X-rays rarely reveal unknown complications in total hip arthroplasty [16]. Simultaneous biplane radiography can accurately assess the motion of total joint replacements in vivo [103]. Biplane radiography may become an important adjunct in postoperative management to detect early changes before clinical or radiographic evidence of loosening is apparent [103]. The most predictive radiographic findings for early diagnosis of loosening were progression of radiolucent lines more than two years after the operation [118]. Any new radiolucent line of 1 mm or wider that appeared more than two years postoperatively is a predictive radiographic finding for early diagnosis of loosening [118]. Heterotopic ossification is a common radiographic finding after modern total hip arthroplasty, with prevalence ranging from 10% to 40% depending on the surgical approach [126].

MRI: Preoperative magnetic resonance imaging did not reveal avascular necrosis, a labrum tear, or evident chondral damage in the acetabulum or the femoral head [131].

CT: Parameters derived from cross-sectional CT imaging can be useful additional preoperative planning tools for total hip arthroplasty [125].

Other Considerations: Risk factors for prosthetic hip infection include obesity, primary hip arthroplasty, and anterior surgical approach [5].

Treatment

Non-Operative

Conservative management, including proximal femoral osteotomies, is indicated for secondary juvenile hip osteoarthritis when it fails to improve symptoms and quality of life [116].

Operative

Indications: Primary arthroplasty is preferred for elderly patients with Garden-I and II femoral neck fractures exhibiting posterior tilt above a specific threshold [3]. It serves as a suitable option for end-stage secondary juvenile hip osteoarthritis following failed conservative treatments [116]. Younger patients with femoral neck fracture nonunion may benefit from joint-sparing procedures or arthroplasty using modern implants [15]. Total hip arthroplasty (THA) is increasingly offered for osteoarthritis in patients with fragile or pathologic bone, demonstrating improved functional and patient-reported outcomes [18]. In appropriately selected patients with sickle cell hemoglobinopathies, THA provides significant pain relief and functional restoration despite increased medical risks [93]. THA among nonagenarians can be performed with acceptable perioperative morbidity and mortality [113]. For ankylosing spondylitis patients with stable disease, THA is strongly recommended to mitigate blood loss associated with stiff joints [41]. Percutaneous column fixation and THA is an alternative to combined ORIF and THA for acute acetabular fractures in the elderly, reducing complications from extensive approaches [32]. Hip arthroscopy in patients aged ≥50 years carries a risk of subsequent THA, necessitating rigorous selection and counseling [4].

Surgical Approach / Technique: The posterior approach remains a main technique for primary THA [12]. The mini-anterior (ASI) approach is a safe, minimally invasive method that encourages early functional recovery [13]. All three surgical approaches (posterior, direct lateral, and direct anterior) are safe with excellent results [28]. A modified direct anterior approach preserves anterior benefits while addressing limitations such as the need for traction tables, offering a versatile option [29]. Advances in blood loss and pain management with the direct anterior approach renew interest in one-stage bilateral THA, which avoids a second anesthesia session and shortens overall recovery despite longer operative time [35, 97]. The choice of surgical approach should be based on patient characteristics, surgeon experience, and preference until more rigorous randomized evidence is available [14].

Implant Selection: Cemented fixation is associated with the lowest implant survival across all age groups, including the elderly, whereas all fixation techniques perform well at long-term follow-up [58]. A press-fit porous coated cup without additional augmentation is suggested as the best choice for primary hip arthroplasty in normal anatomy and good bone quality [101]. The Taperloc femoral component provides excellent long-term fixation in primary THA [25]. A straight-stemmed, plasma-sprayed, titanium-alloy, uncemented femoral component affords durable fixation at ten to twelve years [75]. At 15 years, proximally HA-coated tapered titanium femoral components remain well fixed and clinically asymptomatic [57]. Fixation with extensively porous-coated components remains durable through 20-year follow-up, despite revisions for wear in young populations [102]. Cementless primary stems have a role in late fixation failures of intertrochanteric fractures [79]. Removal of trabecular metal osteonecrosis implants and conversion to primary THA is a simple, fast technique that reduces morbidity [33].

Pain Management: Total intravenous anesthesia combined with short-acting spinal anesthetics benefits primary total joint arthroplasty by enabling more day-of-surgery physical therapy and earlier discharge by nearly one full day [23]. Perioperative dexamethasone decreases early pain scores, narcotic consumption, and length of stay in primary direct anterior THA with neuraxial anesthesia [85]. Topical tranexamic acid reduces opioid consumption compared with intravenous use by mitigating the early postoperative inflammatory response [96]. Both non-selective and selective NSAIDs are effective for heterotopic ossification prophylaxis and can be used routinely after THA [109]. Regional or combination regional and general anesthesia offers a highly significant advantage over general anesthesia alone regarding patient satisfaction and opioid requirement [81].

Adjuncts: Joint aspiration is the key diagnostic tool for prosthetic hip infection caused by Cutibacterium avidum, with risk factors including obesity, primary hip arthroplasty, and the anterior surgical approach [5].

Setting of Care: Enhanced recovery after surgery protocols can decrease length of stay even without neuraxial anesthesia in some settings [19]. For carefully selected patients, outpatient THA is a feasible alternative to traditional inpatient THA without compromising 1-year outcomes [21].

Other Considerations: Arthroplasty in dialysis-dependent patients should be approached with caution and preferably delayed until after renal transplantation [46]. Hip arthroplasty in women requires caution by surgeons unfamiliar with resurfacing techniques [34]. Demographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery [95]. Risk factors for revision include demographic, clinical, surgical, implant, and provider variables [2]. Focusing on primary THAs initially performed by contemporary, subspecialty practices allows accurate determination of etiologies and failure rates [1]. Policymakers should consider the long-term benefits of increased productivity when comparing THA with nonsurgical treatments [115].

Complications

Infection (PJI): Periprosthetic joint infection (PJI) is a devastating complication associated with significantly higher mortality risk than major aseptic revisions [139]. PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years [104]. Patients revised for infection had increased mortality rates compared with the general population and those undergoing primary THA or aseptic revision [92]. Risk factors for PJI include increasing BMI following contemporary primary THA [127], prior venous thromboembolism (VTE) after total knee arthroplasty (TKA) [89], and a history of pseudotumour secondary to metal-on-metal (MoM) THA [137]. In a large series of acute PJIs after primary hip arthroplasties treated with single debridement, antibiotics, and implant retention (DAIR), infection-free survival was 77% at five years [130]. Future large randomized controlled trials are needed to directly address the role of rifampin in staphylococcal PJI [135]. The use of intrawound vancomycin powder (IVP) in primary THA was associated with a higher rate of PJI, overall reoperation, reoperation for wound complications, and readmission [134]. The administration of additional antibiotics following skin closure may not be required for primary total joint arthroplasty (TJA), regardless of the patient's preoperative risk of PJI [138]. In primary total knee arthroplasty with asymptomatic elevated inflammatory markers, only 2.2% of patients were revised due to PJI at a mean follow-up of 6.4 years [123].

Aseptic loosening: Aseptic loosening is a primary driver of revision surgery after primary total hip arthroplasty (THA) [1]. It was the most common cause of reoperation following primary THA [91]. Instability and aseptic loosening accounted for nearly 70% of failures requiring a second revision in cementless acetabular components [108]. Survivorship with an endpoint of stem revision for any reason was 93.8% and for aseptic loosening was 100% at 16.8 years in patients younger than 50 with femoral head osteonecrosis undergoing cementless modular THA [98]. Uncemented total hip arthroplasty using a tapered femoral component in obese patients demonstrates durability with a low rate of aseptic loosening [110]. Single-taper primary stems carried a notable rate of failures at 10 years in comparison to single-taper revision stems [105].

Instability: Instability is a key etiology driving revision surgery after primary THA [1]. It accounted for nearly 70% of failures requiring a second revision in cementless acetabular components [108]. Patients who undergo closed reduction for dislocation following primary THA have an alarmingly high risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) [119]. THA performed using either the direct anterior approach (DAA) or posterior approach (PA) has no compelling advantage over each other, including no difference in the dislocation risk [145].

Thromboembolism: The incidence of preoperative DVT in non-fracture patients awaiting total hip arthroplasty was 3.1%, with 2.4% in primary THA and 9.0% in revision THA [59]. Revision THA alone is not an independent risk factor for DVT and pulmonary embolism (PE) when compared to primary hip arthroplasty [88]. Prior VTE significantly increases the risk of 90-day DVT, PE, and 2-year PJI after TKA [89]. Extended-duration prophylaxis was associated with reduced rates of symptomatic DVT and PE following THA [100]. Low-dose aspirin monotherapy was associated with reduced rates of VTE and major postoperative complications compared to alternative strategies in both high-risk and low-risk THA patients [106]. The incidence of DVT in patients undergoing DAA hip arthroplasty was low, and occurrence was related to multiple factors [56].

Periprosthetic fracture: At a mean follow-up of 6.4 years, periprosthetic fractures occur annually in 26 per 10,000 persons a decade after primary total hip replacement and are especially frequent in those with prior total knee or revision total hip replacements [112].

Wound complications: Surgical site complications requiring readmission or reoperation should be considered major complications when reporting results and guidelines for VTE prophylaxis in THA/TKA [111].

Other Considerations: Revision surgery after primary THA is driven by etiologies including aseptic loosening, instability, and PJI [1]. A range of demographic, clinical, surgical, implant, and provider variables are associated with the risk of revision following primary THA [2]. Primary total hip arthroplasty achieves minimal clinically important difference significantly faster than revision total hip arthroplasty across multiple patient-reported outcome measures [10]. The long-term outcome of cemented primary and subsequent revision THA is promising in patients under 50 years of age [11]. The Taperloc femoral component provides excellent long-term fixation in patients undergoing primary total hip arthroplasty [25]. Between 1991 and 2005, primary and revision THA use increased substantially, but regionalization of THA was not evident as the percentage of procedures performed in high-volume hospitals remained relatively stable [27]. Dialysis-dependent patients undergoing primary THAs had high 5-year mortality (35%) but an acceptably low cumulative incidence of any revision [107]. Rurality is not associated with 90-day readmissions or complications after primary THA or TKA independent of patients’ underlying geographic social vulnerability, but social determinants of health (SDOH) as described by the composite Social Vulnerability Index (SVI) ranking were associated with 90-day readmission rates in primary THA and 90-day complications in primary TKA in the most vulnerable patient populations [124]. Patients undergoing primary and revision knee arthroplasty had lower mortality rates than their age- and sex-matched peers from the general population [136]. Failure rates for primary total hip arthroplasty in patients with osteonecrosis are similar to those found in the general population, with differences in failure rates related to the underlying risk factors for the disease [142]. The outcome of survival rate and application number of total hip arthroplasty in patients with femoral neck fracture is heavily dependent on the primary data of included manuscripts and register reports, with limitations regarding dislocation reporting, infection risk factors, and fracture differentiation [143]. Inpatient mortality rate after primary total hip arthroplasty was 0.13% [144].

Recovery

Light activity (weeks): Early functional recovery is encouraged through specific surgical and anesthetic strategies. The mini-anterior approach (ASI) serves as a safe, minimally invasive method for primary total hip replacement that facilitates this early return to function [13]. Furthermore, utilizing total intravenous anesthesia combined with short-acting spinal anesthetics provides distinct benefits, including more day-of-surgery physical therapy sessions and an earlier discharge by nearly 1 full day for patients undergoing primary total joint arthroplasty [23].

Full activity (months): Functional trajectories vary significantly based on surgical approach and patient comorbidities. In patients with hip arthroplasty on the contralateral side who had below knee amputation, functional recovery is delayed until 3 months after anterolateral approach (ALA) compared with posterolateral approach (PA) [80]. Conversely, the direct superior approach (DSA) promotes early recovery and better mid-term functional outcomes compared to the posterolateral approach in mid-term clinical outcomes of total hip arthroplasty [146]. Patients treated with hip resurfacing arthroplasty demonstrate high activity levels and engage in many different sport disciplines 2 years after surgery [70].

Complete recovery / outcome plateau (months): Long-term stability and final outcomes are well-documented across various cohorts. Patients in unilateral THA and bilateral THA groups increased their physical function and decreased pain after one-year follow-up of the primary THA operation, with conditions remaining stable after five years of operation [78]. Clinical and functional improvements of total hip arthroplasty with ceramic-on-ceramic (CoC) bearing are maintained at 7 years postoperative [140]. Primary total hip arthroplasty achieves minimal clinically important difference significantly faster than revision total hip arthroplasty across multiple patient-reported outcome measures [10].

Rehabilitation protocol: 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 [17]. For the elderly population, THA in patients over 75 years gives patients the best opportunity to return to premorbid function, but when complications occur there is a catastrophic effect on independence [77].

Functional milestones: Revision outcomes following primary procedures show high satisfaction. Patients undergoing revision after hip resurfacing arthroplasty (HRA) can expect to achieve function and quality of life similar to their best after their primary surgery, while the risk of re-revision is low [82]. Long-term durability is also evident in younger cohorts, where 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 [141].

Other Considerations: Preoperative counseling and postoperative adherence are critical for optimal outcomes. Patient compliance with follow-up at one year postoperatively after primary hip and knee arthroplasty is low [71]. Additionally, patients undergoing primary joint arthroplasty of the hip and knee demonstrate significant ethnic and sex differences regarding expectations and knowledge of the intervention, which play a major role in the use and outcome of joint arthroplasty cases [6].

Key Evidence

  • [L4] Focusing on primary THAs initially performed by a contemporary, subspecialty practice allowed an accurate determination of etiologies and rates of failure after THA. (10.5435/jaaos-d-17-00842)
  • [L1] This systematic review of literature published between 2000 and 2010 identified a range of demographic, clinical, surgical, implant, and provider variables associated with the risk of revision following primary THA. (10.1186/1471-2474-13-251)
  • [L2] The authors suggest that primary arthroplasty may be preferred for fractures with a degree of posterior tilt above a certain threshold. (10.2106/jbjs.18.01256)
  • [L4] However, due to potential for subsequent need for THA in a subset of this population, surgeons should use rigorous selection criteria and counsel patients appropriately. (10.1016/j.arthro.2018.05.034)
  • [L4] Joint aspiration is the key diagnostic tool, and risk factors include obesity, primary hip arthroplasty, and anterior surgical approach. (10.1016/j.arth.2018.02.008)
  • [L4] Patients undergoing primary joint arthroplasty of the hip and knee demonstrate significant ethnic and sex differences regarding expectations and knowledge of the intervention, which play a major role in the use and outcome of joint arthroplasty cases. (10.1016/j.arth.2008.01.296)
  • [L4] The incidence of shoulder arthroplasty in patients less than 50 years old is higher than previously reported, with most cases performed for primary osteoarthritis. (10.1016/j.jse.2023.01.040)
  • [L3] The current data were unable to identify clear advantages of this evolving technology for primary THA. (10.1016/j.arth.2022.12.012)
  • [L2] Patient-reported outcome measures prior to primary knee arthroplasty were comparable across hospitals with differing revision rates. (10.1007/s00167-023-07374-3)
  • [L3] Primary total hip arthroplasty achieves minimal clinically important difference significantly faster than revision total hip arthroplasty across multiple patient-reported outcome measures. (10.1016/j.arth.2024.10.002)
  • [L3] The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. (10.1302/0301-620x.104b3.bjj-2021-0904.r1)
  • [L1] The authors continue to use the posterior approach as the main approach for primary total hip arthroplasty. (10.1016/j.arth.2011.06.007)
  • [L3] The ASI approach is a safe, minimally invasive method for performing primary total hip replacement that encourages early functional recovery. (10.1302/0301-620x.96b11.34348)
  • [L3] Younger patients may be better candidates for joint-sparing procedures or arthroplasty with modern implants and techniques. (10.2106/00004623-200410000-00019)
  • [L3] In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications. (10.1186/s42836-022-00148-1)
  • [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. (10.2106/00004623-200402000-00012)
  • [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)
  • [L5] The authors endorse the need for randomized, multicenter, prospective trials regarding modern general anesthesia vs neuraxial anesthesia for primary total joint arthroplasty and state that enhanced recovery after surgery protocols can be associated with decreased length of stay even in the absence of neuraxial anesthesia in some surgical settings. (10.1016/j.arth.2020.01.059)
  • [L3] For those that qualify after careful selection, outpatient THA might be a feasible alternative to the traditional inpatient THA. (10.1016/j.arth.2019.10.059)
  • [L3] Total intravenous anesthesia combined with short-acting spinal anesthetics provided benefits including more day-of-surgery physical therapy sessions and earlier discharge by nearly 1 full day for patients undergoing primary total joint arthroplasty. (10.5435/jaaos-d-17-00474)
  • [L4] The lineage of hip arthroplasty device predicates reflects a complex ancestral web of equivalency across a wide range of implants, although their material and design properties may be different. (10.5435/jaaos-d-21-00138)
  • [L4] The Taperloc femoral component provides excellent long-term fixation in patients undergoing primary total hip arthroplasty. (10.2106/jbjs.g.00771)
  • [L3] Between 1991 and 2005, primary and revision THA use increased substantially, but there was minimal evidence that regionalization of THA is occurring as the percentage of procedures performed in high-volume hospitals remained relatively stable. (10.1016/j.arth.2011.04.043)
  • [L5] All three surgical approaches (posterior, direct lateral, and direct anterior) are safe and have excellent results in patients undergoing primary total hip arthroplasty. (10.1016/j.arth.2024.10.036)
  • [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. (10.1186/s13018-025-06397-5)
  • [L3] The presence of a mental health diagnosis had a prominent negative influence on primary total hip arthroplasty patients, leading to lower rates of improvement and higher rates of worsening. (10.5435/jaaos-d-23-00538)
  • [L4] This novel technique served as an alternative to traditional combined ORIF and THA, mitigating complications associated with extensive surgical approaches. (10.1016/j.arth.2013.08.009)
  • [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)
  • [L2] Resurfacing arthroplasty should be undertaken with caution by those surgeons unfamiliar with the technique. (10.1016/j.arth.2008.01.232)
  • [L3] A preoperative diagnosis of a stroke in patients undergoing primary shoulder arthroplasty is associated with higher rates of perioperative complications and mortality when compared to a matched cohort. (10.1016/j.jse.2022.10.014)
  • [L3] Results suggest that patients who undergo an arthroplasty following urgent or emergent femoral neck fractures have inferior outcomes to those receiving an arthroplasty for a diagnosis of arthritis. (10.1016/j.arth.2016.05.035)
  • [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. (10.1302/0301-620x.107b8.bjj-2024-1232.r1)
  • [L3] The diagnosis of hypogonadism is associated with an elevated risk of postoperative complications and increased cost of care following primary THA. (10.1016/j.arth.2020.04.009)
  • [L3] It is strongly recommended to perform THA in AS patients with stable disease. (10.1186/s12891-020-03278-2)
  • [L3] Obesity, medical and psychological comorbidity increased and the underlying diagnosis of RA/inflammatory arthritis decreased rapidly in primary THA patients over 13-years. (10.1186/1471-2474-15-441)
  • [L3] Factors potentially associated with the quality of bone bed and biomechanics of the hip might influence the risk of aseptic loosening in this implant. (10.1186/1471-2474-11-243)
  • [L3] Arthroplasty should be approached with caution and preferably should be delayed until after renal transplantation. (10.2106/jbjs.n.01301)
  • [L3] The position of the acetabular component can influence the femoral head penetration of modern HXLPEs. (10.1302/0301-620x.107b5.bjj-2024-1083.r1)
  • [L5] Instability after hip arthroplasty is a common and devastating complication with multifactorial causes. (10.1016/j.arth.2018.01.053)
  • [L1] Compared to manual THA, R-THA improves surgical accuracy without increasing surgical trauma, contributing to the restoration of the patient's original hip biomechanics. (10.1016/j.arth.2025.07.029)
  • [L5] The overall prognosis for a patient managed with a total hip arthroplasty after an acetabular fracture is less favorable than that for one managed with an arthroplasty performed because of primary degenerative arthritis. (10.2106/00004623-200009000-00017)
  • [L5] The anterior-posterior component of the hip contact load has a significant effect on the axial motion of the stem relative to the bone. (10.1186/1749-799x-5-40)
  • [L4] The present study revealed a mismatch between proximal femoral anatomy of a relevant proportion of adult hips and implant geometry of the most common femoral component in total hip arthroplasty. (10.1016/j.arth.2016.02.015)
  • [L3] The incidence of DVT in patients undergoing DAA hip arthroplasty was low and the occurrence of DVT before and after unilateral primary hip arthroplasty performed through DAA was related to multiple factors. (10.1186/s13018-023-04443-8)
  • [L3] At 15 years, all 143 implants remained well fixed and clinically asymptomatic. (10.1007/s11999-008-0550-7)
  • [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. (10.1302/0301-620x.104b2.bjj-2021-1199.r1)
  • [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. (10.1186/s13018-023-04488-9)
  • [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)
  • [L5] The higher hip center gained more bone coverage but decreased the range of hip flexion and internal rotation. (10.1016/j.arth.2016.03.014)
  • [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] The significantly increased spinal sagittal imbalance with altered pelvic mechanics is a potential cause for the reported increased risk of THA dislocations in obese patients. (10.1186/s13018-021-02716-8)
  • [L3] Restoration of the normal hip center of rotation provides good long-term results and allows restoration of leg length and lever arm. (10.1016/j.arth.2007.10.008)
  • [L3] Patients with preoperative acetabular morphological risk factors for dislocation might be better candidates for total hip arthroplasty. (10.1016/j.arth.2023.02.042)
  • [L4] Patients with THA indication other than primary osteoarthritis and receiving a posterior surgical approach, and to a lesser degree spinal pathology, were identified as affecting the rate of dislocation. (10.1016/j.arth.2021.08.031)
  • [L4] Patients treated with hip resurfacing arthroplasty have a high activity level and are engaged in many different sport disciplines 2 years after surgery. (10.1177/0363546506296606)
  • [L4] Patient compliance with follow-up at one year postoperatively after primary hip and knee is low. (10.1302/0301-620x.102b7.bjj-2019-1632.r1)
  • [L3] Our findings suggest that conversion THAs require more resources than primary THAs, as well as advanced revision type components. (10.1016/j.arth.2016.08.036)
  • [L4] This femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty. (10.2106/00004623-200401000-00014)
  • [L3] Patients in unilateral THA and bilateral THA groups had increased their physical function, and pain had decreased after one-year follow-up of the primary THA operation, and condition remained after five years of operation. (10.1186/s12891-023-06743-w)
  • [L3] However, in late fixation failures, there is a role for cementless primary stems. (10.1186/s12891-022-05223-x)
  • [L3] Orthopedic surgeons should pay particular attention in patients with hip arthroplasty on the contralateral side hip who had below knee amputation because functional recovery is delayed until 3 months after ALA compared with PA. (10.1186/s12891-018-2385-z)
  • [L2] We were able to show a highly significant advantage in the use of regional or the combination of regional and general anesthesia in comparison with general anesthesia alone in hip arthroplasty regarding patients' satisfaction and the requirement of opioid pain medication, although maybe below clinical relevance. (10.1016/j.arth.2017.05.038)
  • [L4] Patients undergoing revision after HRA can expect to achieve function and quality of life similar to their best after their primary surgery, while the risk of re-­revision is low. (10.1302/0301-620x.102b10.bjj-2020-0147.r2)
  • [L3] Perioperative dexamethasone is associated with decreased early pain scores, narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with neuraxial anesthesia. (10.1016/j.arth.2020.09.015)
  • [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] The authors suggest a classification system for the length of femoral stems to better organize the discussion on stem length. (10.1302/0301-620x.96b4.33036)
  • [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] Prior VTE significantly increased the risk of 90-day DVT, PE, and 2-year PJI after TKA. (10.1016/j.arth.2026.02.013)
  • [L1] The overall rates of complications and revisions were similar in both groups but were of different types. (10.2106/jbjs.20.00030)
  • [L3] Aseptic loosening was the most common cause of reoperation following primary THA. (10.1016/j.arth.2025.02.032)
  • [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)
  • [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)
  • [L3] Demographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. (10.1016/j.arth.2023.01.011)
  • [L1] Topical use of TXA could relieve the local pain symptoms and reduce opioid consumption compared with intravenous use for patients undergoing primary THA by reduce the early postoperative inflammatory response. (10.1186/s12891-023-06576-7)
  • [L3] The main advantages of single-stage bilateral THA are avoiding a second anesthesia session and having an overall shorter recovery time, despite longer operative time. (10.2106/jbjs.20.00105)
  • [L3] Survivorship with an end point of stem revision for any reason was 93.8% and for aseptic loosening was 100% at 16.8 years. (10.1016/j.arth.2012.08.005)
  • [L3] Primary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. (10.1016/j.arth.2017.03.003)
  • [L2] Extended-duration prophylaxis was associated with reduced rates of symptomatic DVT and PE following THA. (10.1016/j.arth.2025.10.067)
  • [L3] Despite revisions for wear-related complications in this relatively young patient population, the fixation achieved with these extensively porous-coated components remained durable through 20-year follow-up. (10.1016/j.arth.2006.12.088)
  • [L4] Simultaneous biplane radiography can accurately assess the motion of total joint replacements in vivo and may become an important adjunct in postoperative management to detect early changes before clinical or radiographic evidence of loosening is apparent. (10.2106/00004623-198466040-00028)
  • [L3] PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years. (10.2106/jbjs.23.01160)
  • [L3] Single-taper primary stems carried a notable rate of failures at 10 years in comparison to single-taper revision stems. (10.5435/jaaos-d-24-01193)
  • [L2] Low-dose aspirin monotherapy was associated with reduced rates of VTE and major postoperative complications compared to alternative strategies in both high-risk and low-risk THA patients. (10.1016/j.arth.2026.02.049)
  • [L4] Dialysis-dependent patients undergoing primary THAs had high 5-year mortality (35%) but an acceptably low cumulative incidence of any revision. (10.1016/j.arth.2023.04.066)
  • [L3] Instability and aseptic loosening accounted for nearly 70% of failures requiring a second revision. (10.1016/j.arth.2008.01.249)
  • [L1] Both non-selective and selective NSAIDs are effective for heterotopic ossification prophylaxis and can be used routinely after total hip arthroplasty. (10.1302/0301-620x.100b7.bjj-2017-1467.r1)
  • [L2] Surgical site complications requiring readmission or reoperation should be considered major complications when reporting the results and guidelines of future recommendations and studies of VTE prophylaxis in THA/TKA. (10.1016/j.arth.2006.12.018)
  • [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. (10.1186/1471-2474-15-168)
  • [L3] When comparing THA with other nonsurgical treatments, policymakers should consider the longterm benefits associated with increased productivity from surgery. (10.1007/s11999-016-5084-9)
  • [L4] Total hip arthroplasty is a suitable option for end-stage secondary juvenile hip osteoarthritis when proximal femoral osteotomies and conservative treatments fail to improve patients' symptoms and quality of life. (10.1186/s13018-020-01990-2)
  • [L3] The most predictive radiographic findings for early diagnosis of loosening were progression of radiolucent lines more than two years after the operation and any new radiolucent line of 1 mm or wider that appeared more than two years postoperatively. (10.2106/00004623-200112000-00015)
  • [L3] Patients who undergo closed reduction for dislocation following primary THA have an alarmingly high risk of DVT and PE. (10.1016/j.arth.2024.11.020)
  • [L5] The study by Mundi et al. helps to shed light on the devastating complication of PJI following joint replacement surgery—and serves as a call to action to researchers to design, execute, and disseminate high-quality studies on PJI prevention and treatment. (10.2106/jbjs.24.00878)
  • [L3] At a mean follow-up of 6.4 years, overall survival was 96.7%, with only 2.2% of patients revised due to a PJI. (10.1016/j.arth.2024.10.063)
  • [L3] The SDOH as described by the composite SVI ranking was associated with 90-day readmission rates in primary THA and 90-day complications in primary TKA in the most vulnerable patient populations. (10.1016/j.arth.2026.04.011)
  • [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)
  • [L5] Heterotopic ossification is a common radiographic finding after modern total hip arthroplasty, with prevalence ranging from 10% to 40% depending on the surgical approach. (10.5435/jaaos-d-22-01070)
  • [L4] This study supports a relationship between increasing BMI and the long-term risk of PJI following contemporary primary THA. (10.1016/j.arth.2024.03.033)
  • [L3] In this large series of acute PJIs after primary hip arthroplasties treated with a single DAIR, infection-free survival was 77% at five years. (10.1016/j.arth.2025.02.009)
  • [L5] Preoperative magnetic resonance imaging did not reveal avascular necrosis, a labrum tear, or evident chondral damage in the acetabulum or the femoral head. (10.1016/j.arthro.2015.05.008)
  • [L3] The use of IVP in primary THA was associated with a higher rate of PJI, overall reoperation, reoperation for wound complications, and readmission. (10.1016/j.arth.2024.03.063)
  • [L5] Future large randomized controlled trials are needed to directly address the role of rifampin in staphylococcal PJI. (10.1016/j.arth.2023.10.061)
  • [L3] Patients undergoing primary and revision knee arthroplasty had lower mortality rates than their age- and sex-matched peers from the general population. (10.1302/0301-620x.104b1.bjj-2021-0753.r1)
  • [L3] Patients with a history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. (10.1302/0301-620x.106b6.bjj-2023-1370.r1)
  • [L3] This study supports the notion that the administration of additional antibiotics following skin closure may not be required for primary TJA, regardless of the patient's preoperative risk of PJI. (10.2106/jbjs.18.00336)
  • [L2] A PJI following THA is associated with a significantly higher mortality risk than major aseptic revisions. (10.1016/j.arth.2025.06.011)
  • [L2] Clinical and functional improvements of THA with CoC bearing are maintained at 7 years postoperative. (10.1186/s13018-020-02192-6)
  • [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. (10.2106/00004623-200306000-00013)
  • [L1] Failure rates for primary total hip arthroplasty in patients with osteonecrosis are similar to those found in the general population, with differences in failure rates related to the underlying risk factors for the disease. (10.1016/j.arth.2008.11.090)
  • [L5] The authors of the original meta-analysis agree with the letter writers that their outcome is heavily dependent on the primary data of included manuscripts and register reports, acknowledging limitations regarding dislocation reporting, infection risk factors, and fracture differentiation. (10.1016/j.arth.2020.03.054)
  • [L3] Short-term outcome and complication data from a state joint replacement registry demonstrates that THA performed using either the DAA or PA have no compelling advantage over each other, including no difference in the dislocation risk. (10.1016/j.arth.2016.02.071)
  • [L1] These advantages support the use of DSA for promoting early recovery and better mid-term functional outcomes. (10.1186/s12891-024-08271-7)

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