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Research & Methodology

Application of PROMs in orthopaedics, focusing on MCID and PASS thresholds for evaluating surgical success and patient selection.

Overview

Current orthopaedic trauma and sports medicine literature highlights critical gaps in evidence requiring further randomized controlled trials to determine optimal treatment methods, such as ligamentotaxis for closed phalangeal fractures [1] and open versus closed reduction internal fixation for lateral condyle humeral fractures in children [4]. While early results for arthroscopic superior capsular reconstruction in massive, irreparable rotator cuff tears are promising, additional studies are necessary to delineate long-term success, clinical indications, survivorship, and risk factors for failure [9]. Similarly, more high-quality trials are needed to resolve controversies surrounding cementless arthroplasty, generic implants, and arthroscopy [28].

Methodological rigor remains a primary concern across the field. Outcome estimation must aim to identify clinically important differences, present measures of effect with confidence intervals, and minimize bias [5]. However, current studies on biologic preparations like platelet-rich plasma and mesenchymal stem cells often lack the detail necessary for reproducibility or adequate reporting of preparation protocols and composition [14, 16]. Researchers bear the responsibility to ensure appropriate documentation of biologic components to verify true benefits [14], and understanding the evidence for emerging technologies is critical for their appropriate utilization [6].

Future research directions must also address specific procedural and economic evaluations. A protocol has been established for the first randomized trial to evaluate blinding in outpatient total hip arthroplasty compared to standard overnight stay, alongside a prospective full economic evaluation [29]. Clinical assessment following guideline publication is essential to identify future research areas and assess utility for pediatric femoral fractures [2]. Furthermore, understanding indications and identifying potential risk factors before surgical management are essential steps to improving outcomes for hip arthroscopy candidates [31]. Patient needs and proven outcomes must not be compromised by short-term cost savings [28], and researchers must ensure appropriate documentation to verify true benefits [14]. Note that document 00004623-199403000-00020 is a collection of correspondence correcting statistical errors in a previously published trial and does not present new primary data [3].

Anatomy & Pathophysiology

Osseous and Articular Morphology

Hip preservation surgery is not designed to treat irreparable cartilage damage [22]. The cam deformity provides 21% to 27% of the intact hip's resistance to torsional load in flexion and internal rotation [75]. Patients with dysplasia may exhibit increased flexed-hip internal rotation compared to those without dysplasia, though this is significantly decreased by common associated cam morphology [81]. An intraoperative assessment of cartilage thickness may be advisable to express the kinematic alignment philosophy at its full potential [77].

Capsular and Ligamentous Constraints

The capsule plays a predominant role in joint constraint in the hip [75]. Hip microinstability is characterized by abnormal femoral head micromotion within the acetabulum, which leads to cartilage damage and osteoarthritis [74]. This microinstability is often associated with acetabular dysplasia or femoroacetabular impingement syndrome [74]. Increased anterior hip capsular thickness at the femoral head–neck correlates with limitations in hip range of motion in femoroacetabular impingement [82]. In a cadaveric model, 2- and 3-suture constructs resulted in comparable biomechanical failure torques when external rotation forces were applied to conventional hip capsulotomy [70].

Neuromuscular and Kinematic Factors

Strength deficits in hip flexion are associated with decreased function, loss of motion, and larger labral tears in patients with femoroacetabular impingement and labral tears [76]. Athletes exhibiting the greatest reduction in knee abduction moments after an ACL injury prevention program show greater hip adduction excursion at baseline [60]. These athletes also demonstrate corresponding improvements in hip flexion and knee abduction kinematics and hip flexion moments [60]. The orientation and severity of femoral torsion at the time of hip arthroscopy for femoroacetabular impingement syndrome did not affect the propensity for clinically meaningful outcome improvement at midterm follow-up [91].

Clinical Outcomes and Pathomechanics

Hip arthroscopy should not be considered the first choice for all hip pathologies [80]. Surgeons must carefully assess pathomechanics and underlying structural abnormalities like acetabular dysplasia to avoid uncontrolled expansion of hip arthroscopy [80]. Long-term survivorship of hip preservation surgery is expected to improve with advancements in techniques, patient diagnosis, and surgical indications [22]. 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 [88]. 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 [85]. The swan-neck femoral component for patients with congenital dislocation or severe hip dysplasia has a 94% rate of survival at an average of 13.3 years [86]. Segmental electrical bioimpedance equipment can detect differences between limbs affected and unaffected by hip osteoarthritis [83]. Injury risk, and especially non-time-loss hip and groin injury risk, is high in female amateur football [89]. The learning curve for hip arthroscopy was unexpectedly demanding [87].

Classification

FEDS: The FEDS system classifies glenohumeral instability into 16 clinically significant categories [13].

Other Considerations: Observed differences in knee scores between study groups not matched for clinically relevant factors may represent differences in patient populations rather than differences in operative technique or implant design [24]. Detailed comorbidity measures provide no added value over the preoperative Charnley classification for explaining variability in patient-reported outcome scores one year after total hip arthroplasty [72]. The QUIPA tool for evaluating physiotherapy care in hip and/or knee osteoarthritis has confirmed construct validity but inadequate criterion validity for individual items, subscales, and the total score [73]. The document identified as 00004623-199403000-00020 is a collection of correspondence and an addendum correcting statistical errors in a previously published clinical trial rather than a presentation of new primary data or conclusions from a single study design [3].

Clinical Presentation

Clinical assessment following guideline publication is critical to identify areas for future research and evaluate the utility of guidelines for pediatric femoral fractures [2]. For closed phalangeal fractures, further randomized control trials are required to determine the optimal treatment method [1]. In cervical radiculopathy, future research must establish the clinical utility of the neurological examination [12]. Patients presenting with bilateral carpal tunnel syndrome or multiple trigger digits warrant further investigation for amyloidosis [37].

Outcome estimation must aim to identify a clinically important difference, present measures of effect with confidence intervals, and take necessary steps to minimize bias [5]. Regarding adhesive capsulitis, the AdCaB study will provide data on pathogenesis, diagnosis, and staging [34]. For hip preservation surgery, a valid and reliable patient-derived survey addresses a spectrum of preoperative expectations [30]. In femoral neck fractures treated with hemiarthroplasty, patient-specific frameworks may be needed to guide optimal care based on neutrophil-lymphocyte ratios rather than a one-size-fits-all approach [36].

Classification Systems: The FEDS classification contains 16 categories that are clinically significant for glenohumeral instability [13]. Diagnostic Prognosis: Patients with a preoperative diagnosis of osteonecrosis (ON) had worse clinical outcomes than those with other diagnoses following osteochondral allograft transplantation for femoral head cartilage lesions [35]. Traumatic Outcomes: No patient's rating returned to normal following surgical management of traumatic knee dislocation with posterolateral corner injury [38].

Surgical Approaches: Results regarding open versus arthroscopic approaches for internal snapping hip syndrome should be interpreted with caution given the lack of high-quality evidence or direct comparison data [10]. Regenerative Outcomes: All patients presented significant mid-term clinical, functional, and radiological improvement after adipose-derived culture-expanded mesenchymal stem cells implantation in knee focal cartilage defects [17]. Recovery Timelines: The majority of functional and symptomatic improvements following rotator cuff repair occur within the first year, with minimal clinically meaningful gains observed between 1 and 2 years [7]. Long-term Pain: It was uncommon for individual patients to report clinically significant knee pain at multiple follow-up timepoints (2, 6, and 10 years) after ACL reconstruction [15].

Investigations

Plain radiography: Radiography serves as a screening tool for identifying significant glenoid bone loss in traumatic shoulder instability [43]. In the context of anterior cruciate ligament reconstruction using double semitendinosus grafts, standing X-rays demonstrate that the procedure stabilizes the evolution of degenerative lesions [25].

MRI: Magnetic resonance imaging exhibits poor specificity and negative predictive value for hip pathology; consequently, a negative MRI result may warrant further investigation [32]. In lumbar imaging, the presence of a high-intensity zone on a T2-weighted image indicates abnormal disc morphology [58]. Regarding elbow cartilaginous lesions treated with autologous osteochondral mosaicplasty, MRI indicates that the donor site resurfaces with fibrous tissue [62]. While deep learning models can rapidly generate accurate clinical pathology classifications of knee MRI exams from internal and external datasets, caution is required when interpreting results for internal snapping hip syndrome due to a lack of high-quality evidence or direct comparison data [10, 53].

CT: Parameters derived from cross-sectional CT imaging function as useful additional preoperative planning tools for total hip arthroplasty [52]. For evaluating fatty infiltration of the supraspinatus, the axial CT plane provides the highest level of interobserver agreement [65]. Future studies are warranted to evaluate the use of CT imaging with 3D planning to determine the most practical and accurate imaging modality for assessing hip femoral version [27].

Other Considerations: Clinical assessment following guideline publication remains necessary to identify research areas and assess guideline utility [2]. Understanding current evidence and appropriate indications is critical for utilizing emerging technologies in orthopaedic trauma [6]. Studies of higher evidence levels are required for hip arthroscopy management of osteoid osteoma of the acetabulum [8]. Future research is needed to establish the clinical utility of the neurological examination for cervical radiculopathy [12]. Patients with adipose-derived culture-expanded mesenchymal stem cell implantation in knee focal cartilage defects have shown significant mid-term clinical, functional, and radiological improvement [17]. Double semitendinosus anterior cruciate ligament reconstruction is efficient in restoring satisfactory stability for most patients [25]. Improvements in preoperative workup, imaging, and surgical technique are anticipated to yield continued positive results for hip arthroscopy in older nonarthritic patients [47]. Complications of periacetabular osteotomy are increasingly predictable, yet patient counseling must extend beyond radiographic correction to include biological considerations and realistic expectations [49]. Finally, spin is found in nearly half of abstracts of systematic reviews and meta-analyses investigating meniscal allograft transplantation, with misleading reporting being the most common modality [56].

Treatment

Non-Operative

Non-operative management is indicated for moderate, nonprogressive deformity in childhood coxa vara [57] and serves as a viable initial trial for proximal humeral fractures in the elderly to avoid surgical risks, reserving reverse total shoulder arthroplasty for non-responders without compromising ultimate outcomes [51]. Low rates of documented sequelae following nonsurgical management of pediatric proximal phalanx base fractures support treatment parameters that result in clinically insignificant angular and rotational deformity [67]. Current literature on non-operative treatment of isolated medial collateral ligament injuries remains scarce, ranging from low to moderate quality of evidence [46].

Operative

Indications: Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara [57]. Active claims are not a contraindication for hip arthroscopy for femoral-acetabular impingement, though age may impact perceived improvement [40]. Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures, with selection depending on disease stage and patient factors [64].

Surgical Approach / Technique: Favorable results were demonstrated with both surgical dislocation of the hip and arthroscopic treatment of femoroacetabular impingement, showing significant improvement in all patient-reported outcome measures and high patient satisfaction ratings [42]. Three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence, but the risk of reoperation was much higher than expected [54]. Alternative strategies for failure of superior locking clavicle plate by axial pull-out of the lateral screws include using standard compression screws, combining locked and nonlocked screws, or utilizing anterior-inferior plate placement [69].

Implant Selection: Total knee arthroplasty using a cemented single-radius, condylar-stabilized design performed without posterior cruciate ligament sacrifice is a safe and effective option in routine TKA [39]. The majority of functional and symptomatic improvements following rotator cuff repair occur within the first year, with minimal clinically meaningful gains observed between 1 and 2 years [7].

Other Considerations: Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [6]. The overall modest long-term results for arthroscopically treated discoid lateral meniscus in children illustrate the need for improved operative treatments to prevent progressive clinical decline [11]. Bone marrow stimulation combined with hyaluronic acid (BMS + HA) or bone marrow aspirate concentrate (BMS + CBMA) can provide superior outcomes for osteochondral lesions of the talus, albeit with currently limited evidence [45]. The vast majority of osteochondritis dissecans lesions in the paediatric population healed postoperatively regardless of technique, but high-quality trials are required to more appropriately compare the effectiveness of techniques [79]. Non-responders in hip and knee arthroplasty studies had significantly increased mortality and significantly worse baseline scores despite similar demographics and revision risk [48].

Research & Methodology

Further research in the form of randomized control trials is required to determine the best method of treatment for closed phalangeal fractures using ligamentotaxis [1]. Clinical assessment after guideline publication is important to identify areas of potentially important future clinical research and to assess the utility of the guideline for pediatric femoral fractures [2]. Outcome estimation should aim at identifying a clinically important difference, presenting measures of effects with confidence intervals, and taking necessary steps to minimize bias [5]. It is the responsibility of researchers to ensure appropriate documentation of biologic preparation and components to verify true benefits, as current studies often lack the detail necessary for reproducibility and definitive conclusions on efficacy [14]. Currently available literature on stem cell treatment for knee osteoarthritis is limited with few quality papers on which to base recommendations for treatment using MSCs [33]. Intra-articular MSC injection appears safe, but current evidence does not support its routine use or efficacy compared to placebo or other treatments [33]. A prospective trial on acupuncture for hip fracture surgery is expected to provide high-quality evidence for evaluating the effectiveness and safety of acupuncture in postoperative recovery [41]. The treatment of chronic, nonradicular, discogenic low back pain remains controversial, and while intradiskal electrothermal therapy shows reported therapeutic success rates of 60% to 80%, a more precise quantification of clinical benefits remains to be proved in randomized prospective trials [78].

Complications

Other Considerations: Further randomized control trials are required to determine the best method of treatment for ligamentotaxis in closed phalangeal fractures [1]. More high-quality randomized controlled trials are needed to determine the conclusion regarding open versus closed reduction internal fixation for lateral condyle humeral fractures in children [4]. Outcome estimation should aim at identifying a clinically important difference, presenting measures of effects with confidence intervals, and taking the necessary steps to minimize bias [5]. Further studies are necessary to determine the long-term success of arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears and to better delineate clinical indications, survivorship, and risk factors for failure [9]. The overall modest long-term results of arthroscopically treated discoid lateral meniscus in children illustrate the need for improved operative treatments to prevent progressive clinical decline [11]. All existing clinical studies evaluating mesenchymal stem cells for orthopaedic or sports medicine applications are limited by inadequate reporting of both preparation protocols and composition [16]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis for focal cartilage defects in the knee will maintain structural and functional integrity over time [18]. Understanding the natural history and management options is an important part of preventing disability and maintaining independence in an increasingly aging and active Down syndrome population with hip instability [20]. Patient-reported outcome measures like ASES reliably assess long-term reverse shoulder arthroplasty outcomes beyond 1 year, as demonstrated in a Japanese cohort [21]. Hip preservation surgery is not designed to treat irreparable cartilage damage [22], though long-term survivorship is expected to improve with advancements in techniques, patient diagnosis, and surgical indications [22]. The few papers with long-term follow-up on the Dunn procedure modified by Ganz for slipped capital femoral epiphysis reported no progression of hip osteoarthritis, but longer follow-up studies are needed to validate this statement [23]. 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 [24]. The double semitendinosus anterior cruciate ligament reconstruction procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of degenerative lesions as shown by standing X-ray at 10-year results [25]. Patients with underlying inflammatory conditions have similar 2-year outcomes after hip arthroscopy for intra-articular pathology compared with patients with no history of inflammatory disease [26]. Long-term anticoagulation use was associated with poorer medical and surgical outcomes at both 90 days and 2 years postoperatively in patients undergoing unicompartmental knee arthroplasty, even after rigorous adjustment for confounders [44]. Urate-lowering drugs prescribed early during the course of gout had neither adverse nor beneficial effect on the long-term risk of fractures [61]. Evidence for outcomes after hip arthroscopy in patients with femoroacetabular impingement and osteoarthritis of Tönnis Grade 2 or greater is inconclusive and contradictory, drawn from data with low levels of evidence, mainly consisting of retrospective case series with a high risk of bias and high heterogeneity [84]. Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis for mid- to long-term results after bipolar radial head arthroplasty [90]. Despite the high incidence of postoperative degenerative changes in the long term, functional outcomes remain satisfactory for long-term outcomes of arthroscopic Bankart repair at 11-20 years of follow-up [19]. The document is a collection of correspondence and an addendum correcting statistical errors in a previously published clinical trial and does not present new primary data or conclusions from a single study design [3].

Recovery

Light activity (weeks): Evidence regarding specific timelines for light activity, such as desk work or driving, is not explicitly defined in the provided literature for the general population. However, acute ACL reconstruction results in fewer sick-leave days compared to delayed reconstruction [93].

Full activity (months): The majority of functional and symptomatic improvements following primary rotator cuff repair occur within the first year [7]. Acute and delayed ACL reconstruction provided comparable clinical outcomes after 12 months [93]. Patients with underlying inflammatory conditions have similar 2-year outcomes after hip arthroscopy for intra-articular pathology compared with patients with no history of inflammatory disease [26].

Complete recovery / outcome plateau (months): Minimal clinically meaningful gains are observed between 1 and 2 years following primary rotator cuff repair [7]. It was uncommon for individual patients to report clinically significant knee pain at multiple follow-up timepoints (2, 6, and 10 years) after ACL reconstruction [15]. At minimum 10-year follow-up, a low incidence of clinically relevant radiographic osteoarthritis was observed in patients who underwent primary repair of the anterior cruciate ligament [59]. Despite a high incidence of postoperative degenerative changes, functional outcomes remain satisfactory at 11-20 years of follow-up after arthroscopic Bankart repair [19]. Three distinct response trajectories in patients undergoing total knee arthroplasty were identified [95].

Rehabilitation protocol: Further research in the form of randomized control trials is required to determine the best method of treatment for closed phalangeal fractures treated with ligamentotaxis [1]. Further studies are necessary to better delineate the clinical indications, survivorship, and risk factors for failure of arthroscopic superior capsular reconstruction in this population [9]. Long-term clinical follow-up of patients treated with endoscopic gluteal repair with or without concomitant hip arthroscopy should be included in large national and international prospective registries [55].

Functional milestones: Patient-reported outcome measures like ASES reliably assess long-term reverse shoulder arthroplasty outcomes beyond 1 year [21]. The Musculoskeletal Function Assessment Questionnaire was more responsive than the SF-36 in measuring changes in function between baseline and follow-up values [50]. The Musculoskeletal Function Assessment Questionnaire was more efficient than the SF-36 in measuring changes in function between baseline and follow-up values [50]. Validated, reliable, and responsive patient-reported outcome scores should be used to assess clinical importance using the minimal clinically important difference, patient acceptable symptom state, substantial clinical benefit, and maximal outcome improvement [55].

Other Considerations: Early results for arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears are promising [9]. Further studies are necessary to determine the long-term success of arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears [9]. Overall modest long-term results are observed after arthroscopically treated discoid lateral meniscus in children [11]. Improved operative treatments are needed to prevent progressive clinical decline in children with discoid lateral meniscus [11]. Further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time following autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [18]. Understanding the natural history and management options is important for preventing disability and maintaining independence in patients with Down syndrome and hip instability [20]. The few papers with long-term follow-up on the Dunn procedure modified by Ganz for slipped capital femoral epiphysis reported no progression of hip osteoarthritis [23]. Longer follow-up studies are needed to validate the statement that the Dunn procedure modified by Ganz prevents progression of hip osteoarthritis in adolescent patients [23]. Mobile and fixed-bearing (all-polyethylene tibial component) total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [92]. The interpretation of findings regarding the treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells is limited because of the small number of patients [94]. The interpretation of findings regarding the treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells is limited because of the short duration of follow-up [94].

Key Evidence

  • [L2] Further research in the form of randomized control trials is required to determine the best method of treatment. (10.1177/17531934251350453)
  • [L4] This analysis suggests an important role for clinical assessment after guideline publication to identify areas of potentially important future clinical research and to assess the utility of this guideline. (10.2106/jbjs.o.00161)
  • [L1] More high-quality randomized controlled trials are needed to determine this conclusion. (10.1186/s13018-023-03808-3)
  • [L5] Outcome estimation should aim at identifying a clinically important difference, at presenting measures of effects with confidence intervals and at taking the necessary steps to minimize bias. (10.1302/2058-5241.3.170064)
  • [L4] The majority of functional and symptomatic improvements following RCR occur within the first year, with minimal clinically meaningful gains observed between 1 and 2 years. (10.1016/j.jse.2025.05.020)
  • [Case_report] Studies of higher level of evidence are required. (10.1186/s12891-015-0779-8)
  • [L1] Although early results are promising, further studies are necessary to determine the long-term success of this technique and to better delineate the clinical indications, survivorship, and risk factors for failure in this population. (10.1016/j.arthro.2018.09.033)
  • [L4] However, given the lack of high-quality evidence or direct comparison data, these results should be interpreted with caution. (10.1016/j.arthro.2013.01.016)
  • [L3] The overall modest long-term results illustrate the need for improved operative treatments to prevent progressive clinical decline. (10.1007/s00167-017-4825-y)
  • [L4] Future research should address these issues to establish the clinical utility of the neurological examination for cervical radiculopathy. (10.1186/s12891-025-08560-9)
  • [L4] There are 16 categories within the FEDS classification that are clinically significant. (10.1016/j.jse.2018.08.014)
  • [Commentary] It is the responsibility of researchers to ensure appropriate documentation of biologic preparation and components to verify true benefits, as current studies often lack the detail necessary for reproducibility and definitive conclusions on efficacy. (10.1016/j.arthro.2019.08.016)
  • [L2] Despite this finding, it was uncommon for individual patients to report clinically significant knee pain at multiple follow-up timepoints. (10.1177/03635465251414661)
  • [L1] All existing clinical studies evaluating MSCs for orthopaedic or sports medicine applications are limited by inadequate reporting of both preparation protocols and composition. (10.1177/0363546518758667)
  • [L4] The findings demonstrate that all patients presented significant mid-term clinical, functional and radiological improvement. (10.1007/s00167-019-05688-9)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L4] Despite the high incidence of postoperative degenerative changes in the long term, functional outcomes remain satisfactory. (10.1016/j.jse.2025.04.015)
  • [L5] Understanding the natural history and management options is an important part of preventing disability and maintaining independence in an increasingly aging and active Down syndrome population. (10.5435/jaaos-d-17-00179)
  • [L4] PROMs like ASES reliably assess long-term rTSA outcomes, as demonstrated in this Japanese cohort. (10.1016/j.jseint.2026.101646)
  • [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)
  • [L3] The few papers with long term follow-up reported no progression of hip osteoarthritis, however, since the patients are adolescent at surgery, longer follow-up studies are needed to validate this statement. (10.1186/s12891-022-05071-9)
  • [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)
  • [L4] The study shows that the procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of the degenerative lesions as shown by standing X-ray. (10.1007/s001670050076)
  • [L3] Patients with underlying inflammatory conditions have similar 2-year outcomes after hip arthroscopy for intra-articular pathology compared with patients with no history of inflammatory disease. (10.1016/j.arthro.2020.01.017)
  • [L5] Future studies are warranted to evaluate the use of CT imaging with 3D planning to determine the most practical and accurate imaging modality. (10.1016/j.arthro.2024.01.011)
  • [L5] The editorial argues that more data and methodologically sound studies are needed to resolve controversies in orthopaedic surgery, including cementless arthroplasty, generic implants, and arthroscopy, while emphasizing that patient needs and proven outcomes must not be compromised by short-term cost savings. (10.1302/0301-620x.98b7.38073)
  • [L2] This protocol describes the first randomized trial to use blinding to evaluate outpatient THA compared to standard overnight stay and the first to prospectively perform a full economic evaluation. (10.1186/s12891-020-03699-z)
  • [L2] We developed a patient-derived survey that is valid, reliable, and addresses a spectrum of expectations. (10.1016/j.arthro.2016.11.012)
  • [Commentary] Understanding indications and identifying potential risk factors before surgical management are essential steps to improving overall patient outcomes. (10.1016/j.arthro.2019.07.011)
  • [L3] However, MRI has poor specificity and negative predictive value, and thus, a negative MRI result may warrant further investigation. (10.1186/s13018-018-0832-z)
  • [Commentary] Currently available literature is limited with few quality papers on which to base recommendations for treatment using MSCs; while intra-articular MSC injection appears safe, current evidence does not support its routine use or efficacy compared to placebo or other treatments. (10.1016/j.arthro.2018.08.027)
  • [L5] This study will provide much needed information regarding the pathogenesis, diagnosis and staging of AC. (10.1186/s12891-019-2536-x)
  • [L4] Patients who had a preoperative diagnosis of ON had worse clinical outcomes than those who had other diagnoses. (10.1016/j.arth.2024.06.030)
  • [L2] These findings suggest that patient-specific frameworks may be needed to guide optimal care rather than a one-size-fits-all approach. (10.5435/jaaos-d-24-01357)
  • [L4] Patients with these presentations warrant further investigation for amyloidosis. (10.1016/j.jhsa.2023.05.008)
  • [L4] No patient's rating returned to normal. (10.1016/j.arthro.2012.11.021)
  • [L3] The findings of excellent implant survival, safety, and functional outcomes indicate that this combination is a safe and effective option in routine TKA. (10.1302/0301-620x.106b8.bjj-2023-1371.r1)
  • [L3] Active claims are not a contraindication for the procedure, but age may impact perceived improvement. (10.1016/j.arthro.2015.10.005)
  • [L2] This prospective trial is expected to provide high-quality evidence for evaluating the effectiveness and safety of acupuncture in postoperative recovery from hip fracture, potentially offering new options for clinical treatment. (10.1186/s13018-025-06450-3)
  • [L2] Favorable results were shown with both approaches, with significant improvement in all patient-reported outcome measures and high patient satisfaction ratings. (10.1016/j.arthro.2013.06.010)
  • [L4] Radiography can be used for screening patients for significant glenoid bone loss. (10.1186/s12891-015-0607-1)
  • [L3] This study demonstrated that long-term anticoagulation use was associated with poorer medical and surgical outcomes at both 90 days and 2 years postoperatively in patients undergoing UKA, even after rigorous adjustment for confounders. (10.1016/j.arth.2024.02.021)
  • [L2] BMS + HA and BMS + CBMA can provide superior outcomes, albeit the currently limited evidence. (10.1007/s00167-022-07130-z)
  • [L4] The current literature on non-operative treatment of isolated MCL injuries is scarce and ranges from low to moderate quality of evidence. (10.1016/j.jisako.2025.100835)
  • [L5] With improvements in preoperative workup, imaging, and surgical technique, the authors anticipate continued positive results in this population. (10.1016/j.arthro.2016.09.026)
  • [L3] Non-responders had significantly increased mortality and significantly worse baseline scores despite similar demographics and revision risk. (10.1302/0301-620x.108b1.bjj-2025-0683.r1)
  • [L4] Complications are increasingly predictable, and patient counseling must extend beyond radiographic correction to include biological considerations and realistic expectations. (10.1016/j.arth.2026.01.056)
  • [L3] It was more responsive than the SF-36 and more efficient in measuring changes in function between baseline and follow-up values. (10.2106/00004623-199709000-00006)
  • [L1] Given the risks associated with surgery in the elderly population, consideration may be given to an initial trial of nonoperative treatment in these patients, saving RTSA for those in whom nonoperative treatment fails without compromising the ultimate outcome. (10.1016/j.jse.2018.10.004)
  • [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)
  • [L2] Our deep learning model can rapidly generate accurate clinical pathology classifications of knee MRI exams from both internal and external datasets. (10.1371/journal.pmed.1002699)
  • [L3] The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected. (10.1016/j.arth.2024.03.049)
  • [L5] Long-term clinical follow-up of patients treated with endoscopic gluteal repair with or without concomitant hip arthroscopy should be included in large national and international prospective registries using validated, reliable, and responsive patient-reported outcome scores, with clinical importance assessed using the minimal clinically important difference, patient acceptable symptom state, substantial clinical benefit, and maximal outcome improvement. (10.1016/j.arthro.2024.01.013)
  • [L4] Spin is found in nearly half of abstracts of systematic reviews and meta-analyses investigating meniscal allograft transplantation, with misleading reporting being the most common modality of spin. (10.1177/03635465251380850)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L1] The presence of an HIZ on a lumbar MRI T2-weighted image indicates abnormal disc morphology. (10.1186/s13018-017-0523-1)
  • [L4] At minimum 10-year follow-up, a low incidence of clinically relevant radiographic osteoarthritis was observed in patients who underwent ACLPR. (10.1177/23259671261422236)
  • [L1] After an ACL-IPP, athletes that exhibit the greatest reduction in knee abduction moments exhibit greater hip adduction excursion at baseline and show corresponding improvements in hip flexion and knee abduction kinematics and hip flexion moments. (10.1007/s00167-018-5158-1)
  • [L1] Urate-lowering drugs prescribed early during the course of disease had neither adverse nor beneficial effect on the long-term risk of fractures. (10.1186/s13018-019-1317-4)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L3] The axial CT plane should be used when evaluating fatty infiltration as it provides the highest level of interobserver agreement. (10.1016/j.jse.2008.12.014)
  • [L3] Low rates of documented sequelae after nonsurgical management were seen, allowing for the establishment of treatment parameters that result in clinically insignificant angular and rotational deformity. (10.5435/jaaos-d-22-00940)
  • [L4] Alternative strategies include using standard compression screws, combining locked and nonlocked screws, or utilizing anterior-inferior plate placement. (10.1016/j.jse.2008.05.042)
  • [L5] The 2- and 3-suture constructs resulted in comparable biomechanical failure torques when external rotation forces were applied to conventional hip capsulotomy in a cadaveric model. (10.1177/0363546516666353)
  • [L5] Detailed comorbidity measures have no added value to the preoperative Charnley classification in explaining patient-reported outcome score variability. (10.1007/s11999-015-4252-7)
  • [L4] Construct validity was confirmed but criterion validity for individual items, subscales and the total score was inadequate. (10.1186/s12891-020-03221-5)
  • [L5] Although the capsule played a predominant role in joint constraint, the cam deformity provided 21% to 27% of the intact hip's resistance to torsional load in flexion and internal rotation. (10.1177/0363546518815159)
  • [L4] Strength deficits in hip flexion were associated with decreased function, loss of motion, and larger labral tears in patients with FAI and labral tears. (10.1016/j.arthro.2015.04.095)
  • [L4] An intraoperative assessment of cartilage thickness may be advisable to express the kinematic alignment philosophy at its full potential. (10.1002/ksa.12408)
  • [L5] The treatment of chronic, nonradicular, discogenic low back pain remains controversial, and while intradiskal electrothermal therapy shows reported therapeutic success rates of 60% to 80%, a more precise quantification of clinical benefits remains to be proved in randomized prospective trials. (10.5435/00124635-200301000-00003)
  • [L4] The vast majority of lesions healed postoperatively regardless of technique, but high-quality trials are required to more appropriately compare the effectiveness of techniques. (10.1007/s00167-013-2531-y)
  • [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)
  • [L3] Despite having similar preoperative pain and functional profiles to patients without dysplasia, dysplasia patients may have increased flexed-hip internal rotation, which is significantly decreased by common associated cam morphology. (10.1016/j.arthro.2017.08.285)
  • [L4] Increased anterior hip capsular thickness at the femoral head–neck correlates with limitations in hip range of motion in FAI. (10.1007/s00167-018-4915-5)
  • [L4] The segmental electrical bioimpedance equipment can detect differences between limbs affected and unaffected by hip osteoarthritis. (10.1186/s12891-023-06541-4)
  • [L1] This conclusion is drawn from data with low levels of evidence, mainly consisting of retrospective case series with a high risk of bias and high heterogeneity. (10.1016/j.arthro.2022.01.024)
  • [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)
  • [L4] The excellent clinical and radiographic results associated with the swan-neck femoral component, and the 94% rate of survival, at an average of 13.3 years indicate that the biomechanical objectives of this custom-designed prosthesis for patients with congenital dislocation or severe hip dysplasia were met. (10.2106/00004623-200202000-00006)
  • [L3] The learning curve for hip arthroscopy was unexpectedly demanding. (10.1177/0363546517749219)
  • [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)
  • [L3] Injury risk, and especially non-time-loss hip and groin injury risk, is high in female amateur football. (10.1007/s00167-018-4996-1)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
  • [L3] The orientation and severity of femoral torsion at the time of hip arthroscopy for FAIS in this study's cohort did not affect the propensity for clinically meaningful outcome improvement at midterm follow-up. (10.1177/03635465231182151)
  • [L1] The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. (10.2106/jbjs.j.00157)
  • [L2] Acute and delayed ACLR provided comparable clinical outcomes after 12 months. (10.1007/s00167-019-05397-3)
  • [L2] Although the findings of this study are promising, their interpretation is limited because of the small number of patients and the short duration of follow-up. (10.2106/jbjs.d.02662)
  • [L2] Three distinct response trajectories in patients undergoing TKA were identified. (10.1302/0301-620x.103b6.bjj-2020-1821.r1)

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[82] Hip capsular thickness correlates with range of motion limitations in femoroacetabular impingement. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-4915-5

[83] Segmental bioelectrical impedance analysis can detect differences between the affected and non-affected limbs in individuals with hip osteoarthritis. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06541-4

[84] Inconclusive and Contradictory Evidence for Outcomes After Hip Arthroscopy in Patients With Femoroacetabular Impingement and Osteoarthritis of Tönnis Grade 2 or Greater: A Systematic Review. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.01.024

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[89] Hip and groin injury is the most common non‐time‐loss injury in female amateur football. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-4996-1

[90] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

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[92] Mobile and Fixed-Bearing (All-Polyethylene Tibial Component) Total Knee Arthroplasty Designs. Journal of Bone and Joint Surgery. 2010. DOI: 10.2106/jbjs.j.00157

[93] Acute reconstruction results in less sick-leave days and as such fewer indirect costs to the individual and society compared to delayed reconstruction for ACL injuries. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05397-3

[94] Treatment of Osteonecrosis of the Femoral Head with Implantation of Autologous Bone-Marrow Cells. Journal of Bone and Joint Surgery. 2005. DOI: 10.2106/jbjs.d.02662

[95] Patients follow three distinct outcome trajectories following total knee arthroplasty. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b6.bjj-2020-1821.r1

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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.