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Surgical Interventions

Surgical management of hip pathology, ranging from joint preservation and arthroscopy for FAI to complex reconstruction and arthroplasty.

Overview

Arthroscopic reduction in walking-age children with developmental hip dysplasia following failed closed reduction is a quick, safe procedure with no reported medium-term post-operative complications [2]. For older nonarthritic patients, positive outcomes are anticipated for hip arthroscopy given advancements in preoperative workup, imaging, and surgical technique [4]. In the specific cohort of patients with borderline hip dysplasia, arthroscopic surgery utilizing labral preservation and capsular plication requires strict patient selection criteria and must be performed by surgeons with expertise in advanced arthroscopic techniques [21].

Complete capsular closure is established as the standard of care in hip arthroscopy, as it restores native anatomy, improves patient-reported outcomes, and reduces both complications and revision surgery rates compared to incomplete closure [6]. While definitive rules for managing multiligament knee injuries should not be applied universally, decision-making regarding medial-side repair must be individualized for each patient [10]. Similarly, ultrasound-guided release of lateral snapping hip offers a novel surgical option with encouraging results for patients who have failed conservative protocols [11].

Understanding the current evidence and appropriate indications for emerging technologies in orthopaedic trauma is critical for their utilization [5]. Application of defined modes of failure to large clinical series will further establish how to improve the efficacy of joint-preserving hip surgery [3]. In clinical practice regarding the direct anterior approach for simultaneous bilateral total hip arthroplasty, strict compliance with operative indications and prevention of early complications require heightened attention [13].

Anatomy & Pathophysiology

Osseous Morphology and Classification

Hip microinstability is characterized by abnormal femoral head micromotion within the acetabulum, leading to cartilage damage and osteoarthritis [46], and is often associated with acetabular dysplasia or femoroacetabular impingement syndrome [46]. Current classification of borderline hip dysplasia based solely on lateral center edge angle is insufficient [63]; the focus for borderline hip dysplasia must shift to assessing hip instability to better predict treatment outcomes and the need for bony realignment [63]. In patients with dysplasia, flexed-hip internal rotation is significantly decreased by common associated cam morphology [51], whereas patients with dysplasia may have increased flexed-hip internal rotation compared to patients without dysplasia [51]. Dysplasia patients have similar preoperative pain and functional profiles to patients without dysplasia [51]. Custom-made cementless prostheses should be considered as a treatment option for osteoarthritis secondary to Legg-Calve-Perthes disease in the presence of abnormal proximal femoral and acetabular anatomy [70].

Kinematics and Surgical Alignment

Hip stability was achieved in twenty-three of the twenty-five patients following double innominate osteotomy [61]. Hip arthroscopy in patients with acetabular retroversion resulted in no difference in functional outcomes compared with patients with normal version [59]. Atypical posterior hip pain is an uncommon presentation of femoroacetabular impingement [71]. Aligning the stem close to femoral anteversion 10 mm above the lesser trochanter often led to the desired component anteversion in robotic-assisted total hip arthroplasty [72], while stem anteversion is not affected by proximal femur geometry in robotic-assisted total hip arthroplasty [72]. Optimal timing for surgical intervention in the femoroacetabular impingement treatment algorithm remains elusive [9], yet time is of the essence for surgical intervention in femoroacetabular impingement unless surgical intervention has little effect on the natural history of the diseased hip [9].

Long-Term Outcomes and Soft Tissue Mechanics

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 [53]. The trochanteric detachment method avoids tensile forces and creates compressive forces, which contributes to the quality of bone repair [67].

Classification

Hip Pathology Management: Managing borderline dysplasia requires an experienced surgeon to selectively manage multiple aspects of hip pathology to optimize outcomes in a defined cohort [1]. Arthroscopic reduction in walking-age children with developmental hip dysplasia after failed closed reduction is a quick and safe method that can be performed without post-operative complications over the medium term [2]. Concomitant hip arthroscopy and periacetabular osteotomy, once controversial, has become a standard practice in the field with widespread adoption [24]. For precollapse subchondral insufficiency fracture of the femoral head (SIFFH), a new arthroscopic classification system guides treatment: unstable lesions are treated with bioabsorbable pin stabilization, while stable lesions receive treatment of associated intra-capsular pathology [44].

Arthroscopy Outcomes and Indications: Complete capsular closure in hip arthroscopy restores native anatomy, improves patient-reported outcomes, and reduces complications and revision surgery rates compared to incomplete closure [6]. The proposed scoring system for primary hip arthroscopy for femoroacetabular impingement in adolescents may guide decision-making and predict those less likely to have a successful outcome with surgical gluteus medius/minimus [40]. Application of defined modes of failure to large clinical series assists in establishing how to improve the efficacy of joint-preserving surgery of the hip [3].

Knee Injury Decision Making: Decision making regarding medial-side repair in the treatment of multiligament knee injuries must be individualized for each patient, and definitive rules should not be applied to all [10]. 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 [25].

Other Considerations: Understanding current evidence and appropriate indications is of critical importance for the utilization of emerging technologies in orthopaedic trauma [5]. Subtle differences in diagnosis-specific thresholds of Minimal Clinically Important Difference and Patient Acceptable Symptom State in Hip Disability and Osteoarthritis Outcome Score after primary total hip arthroplasty may have a significant impact when used as indicators of operative success in a population setting [12]. Reaching a consensus on a core outcome set is essential to facilitate data pooling for evidence synthesis and meta-analysis in hip fracture surgery [19]. The technique described for stem revision provides reproducibly good results in the treatment of failed osteosynthesis for Vancouver types B1 periprosthetic fractures of the hip [49].

Clinical Presentation

Managing borderline dysplasia and optimizing outcomes in defined cohorts requires an experienced surgeon to selectively address multiple aspects of hip pathology [1]. For developmental hip dysplasia in walking-age children following failed closed reduction, arthroscopic reduction serves as a quick, safe method with no medium-term post-operative complications [2]. In the context of femoroacetabular impingement (FAI), both surgical dislocation and arthroscopic treatment demonstrate favorable results with significant improvements in patient-reported outcomes and high satisfaction at an average 2-year follow-up [20]. Success in FAI arthroscopy is associated with younger age, normal joint space, and specific preoperative score characteristics [7]. While optimal timing for surgical intervention in the FAI algorithm remains elusive unless surgery has little effect on natural history [9], improvements in preoperative workup, imaging, and technique are anticipated to yield continued positive results for hip arthroscopy in older nonarthritic patients [4].

Capsular management is a critical determinant of outcome; complete capsular closure restores native anatomy, improves patient-reported outcomes, and reduces complications and revision rates compared to incomplete closure [6]. In the realm of orthopaedic trauma, understanding current evidence and appropriate indications is critical for utilizing emerging technologies [5]. For acetabular fractures, the effect of radiation therapy versus usual care for heterotopic ossification prophylaxis on functional outcomes remains unclear due to the rarity of subsequent excision surgery [8]. Regarding multiligament knee injuries, decision-making for medial-side repair must be individualized as definitive rules should not apply to all patients [10]. Female patients with medial versus lateral multiligament-injured, dislocated knees demonstrate less favorable clinical outcomes than male patients [32].

Surgical indications vary by pathology and patient demographics. For coxa vara in childhood, surgery is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, whereas moderate nonprogressive deformity often does not require intervention [14]. Ultrasound-guided release of lateral snapping hip offers a novel surgical option with encouraging results for patients failing conservative protocols [11]. In total hip arthroplasty, subtle differences in diagnosis-specific thresholds of minimal clinically important difference and patient acceptable symptom state may significantly impact the assessment of operative success in a population setting [12]. For the direct anterior approach in simultaneous bilateral total hip arthroplasty, strict compliance with operative indications and prevention of early complications require heightened attention [13].

Infection and cartilage management also present specific clinical presentations. Prompt surgical treatment with debridement and implant retention (DAIR), following strict diagnostic and therapeutic criteria, can lead to high success rates in eradicating periprosthetic joint infection [33]. For knee focal cartilage defects, all patients treated with adipose-derived culture-expanded mesenchymal stem cell implantation presented significant mid-term clinical, functional, and radiological improvement [16]. Patients undergoing total knee replacement are expected to present similar performance at 1 year postoperatively following preoperative strengthening plus balance training [17]. Finally, reaching a consensus on a core outcome set is essential to facilitate data pooling for evidence synthesis and meta-analysis in hip fracture surgery [19], while applying modes of failure to large clinical series assists in establishing how to improve the efficacy of joint-preserving hip surgery [3].

Investigations

Plain radiography: Evaluation of recurrent hip instability requires a focused and targeted radiographic assessment alongside a thorough history and physical examination [55]. In the context of femoroacetabular impingement (FAI), understanding current evidence and appropriate indications for emerging technologies is critical for their utilization in orthopaedic trauma [5]. Optimal timing for surgical intervention in the FAI treatment algorithm remains elusive unless surgical intervention has little effect on the natural history of the diseased hip [9].

MRI: Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [47].

Other Considerations: Managing borderline dysplasia requires an experienced surgeon to selectively manage multiple aspects of hip pathology to optimize outcomes in a defined cohort [1]. Application of modes of failure to large clinical series assists in establishing how to improve the efficacy of joint-preserving hip procedures [3]. Improvements in preoperative workup, imaging, and surgical technique are anticipated to yield continued positive results for hip arthroscopy in older nonarthritic patients [4]. Factors associated with successful outcomes in hip arthroscopic surgery for femoroacetabular impingement with capsular management include younger age, normal joint space, and specific preoperative score characteristics [7]. Surgeons are willing to participate in surgical versus nonsurgical trials for femoroacetabular impingement with a 6-month crossover endpoint [58]. Surgeons are reluctant to offer surgical treatment of femoroacetabular impingement without correction of osseous deformity, particularly for cam-type pathomorphology [58].

Surgical Indications and Techniques: Ultrasound-guided release of lateral snapping hip is a novel surgical option with encouraging results in patients for whom conservative protocols have failed [11]. Surgical management for coxa vara in childhood is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, whereas moderate nonprogressive coxa vara deformity in childhood often does not require surgery [14]. Patients with knee focal cartilage defects treated with adipose-derived culture-expanded mesenchymal stem cells implantation presented significant mid-term clinical, functional, and radiological improvement [16]. Constrained acetabular components are recommended only as a salvage measure for severe instability in recurrently dislocating total hip prostheses, not as a first-line treatment option [26]. The direct anterior approach may be a credible option for severely obese patients undergoing total hip arthroplasty, with rates comparable to standard, more extensive approaches and excellent functional and radiographic outcomes [27]. Three methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence, but the risk of reoperation was much higher than expected [28]. Both the direct anterior approach and posterolateral approach yield good results at an average 5-year follow-up in terms of survivorship, function, rate of complications, and radiographic analysis for total hip arthroplasty [30]. Radiological and preliminary clinical results of robotic arm-assisted acetabular reconstruction in revision total hip arthroplasty were satisfactory [35]. Revision total hip arthroplasty performed through the anterior approach has a low dislocation rate and is considered safe and reliable [54]. Reconstruction rings allow the reconstruction of massive acetabular bone defects with relative ease during revision hip surgery [56]. The effect of radiation therapy versus usual care for heterotopic ossification prophylaxis after fixation of acetabular fractures on functional outcomes remains unclear because surgery to perform heterotopic ossification excision is exceedingly rare [8].

Treatment

Non-Operative

Surgical intervention for coxa vara in childhood is indicated specifically for progressive, painful, unilateral deformity or leg-length discrepancy, whereas moderate nonprogressive deformity often does not require surgery [14]. For displaced femoral neck fractures, a recent Cochrane analysis found no arguments favoring either non-cemented or cemented hemiarthroplasty [50]. Regarding acetabular fractures, long-term follow-up (sixteen to twenty-two years) indicates that patients with stable burst fractures treated nonoperatively reported less pain and better function compared with those treated surgically [29].

Operative

Indications: Arthroscopic reduction is appropriate for walking-age children with developmental hip dysplasia following failed closed reduction [2]. Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia requires strict patient selection criteria and should be performed by surgeons with expertise in advanced arthroscopic techniques [21]. For femoroacetabular impingement, successful outcomes are associated with younger age, normal joint space, and specific preoperative score characteristics [7]. Ultrasound-guided release of the lateral snapping hip is a novel surgical option for patients in whom conservative protocols have failed [11]. In clinical practice regarding the direct anterior approach for simultaneous bilateral total hip arthroplasty, strict compliance to operative indications is required to prevent early complications [13].

Surgical Approach / Technique: Complete capsular closure should be embraced as the standard of care in hip arthroscopy as it restores native anatomy, improves patient-reported outcomes, and reduces complications and revision surgery rates compared to incomplete closure [6]. Repair after capsulotomy may be a favorable arthroscopic capsular management technique [57]. Concomitant hip arthroscopy and periacetabular osteotomy has become a standard practice in the field with widespread adoption [24]. Excision of labral amorphous calcification as part of hip arthroscopy for labral tear and femoroacetabular impingement is safe and has favorable and similar outcomes compared with a control group at minimum 2-year follow-up [37]. Iliotibial band autograft provides a safe and effective technique for labral reconstruction with excellent mid- to long-term outcomes, proven effectiveness, durability, versatility, and limited donor-site morbidity [39].

Implant Selection: Use of a constrained acetabular component for salvage of a recurrently dislocating total hip prosthesis is recommended only as a salvage measure for severe instability, not as a first-line treatment option [26]. Three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence, but the risk of reoperation was much higher than expected [28].

Alignment / Balancing Strategy: Application of defined modes of failure to large clinical series will assist in establishing how to improve the efficacy of joint-preserving surgery of the hip [3]. Understanding current evidence and appropriate indications is of critical importance for the utilization of emerging technologies in orthopaedic trauma [5].

Pain Management: The effect of radiation therapy versus usual care for heterotopic ossification prophylaxis after fixation of acetabular fractures through a posterior approach on functional outcomes remains unclear because surgery to perform heterotopic ossification excision remains exceedingly rare [8].

Adjuncts: Decision making regarding medial-side repair in the treatment of multiligament knee injuries must be individualized for each patient, and definitive rules regarding management should not be applied to all [10].

Revision: Short-term symptomatic relief is possible after revision hip arthroscopy, but further study is required to determine long-term outcomes [15].

Other Considerations: Both surgical dislocation of the hip and arthroscopic treatment of femoroacetabular impingement show favorable results with significant improvement in all patient-reported outcome measures and high patient satisfaction ratings [20]. Arthroscopic treatment for femoroacetabular impingement syndrome yields good patient-reported outcomes at the 5-year follow-up [34]. In well-selected patients, periacetabular osteotomy should be considered safe and effective in alleviating pain and improving hip function [36]. Improvements in preoperative workup, imaging, and surgical technique are anticipated to yield continued positive results for hip arthroscopy in older nonarthritic patients [4]. Diagnosis-specific thresholds of minimal clinically important difference and patient acceptable symptom state in the Hip Disability and Osteoarthritis Outcome Score after primary total hip arthroplasty may have a significant impact when used as indicators of operative success in a population setting [12]. Workers' compensation patients undergoing hip arthroscopy for femoroacetabular impingement syndrome experience worse mid-term outcomes but similar return-to-work rates compared to non-workers' compensation patients, although they may take longer to return to work without restrictions [60].

Complications

Infection (PJI): Deep wound sepsis occurs in 1.3 per cent of hips following total hip arthroplasty, with risk factors including previous operations, prolonged operating time, positive culture at operation, and unrecognized preoperative sepsis [31]. Strict compliance to operative indications and prevention of early complications require more attention in clinical practice for the direct anterior approach for simultaneous bilateral total hip arthroplasty [13].

Wound complications: The direct anterior approach for total hip arthroplasty can be safely adopted without significant short-term complication rates for surgeons on the learning curve [42]. Rates of complications for the direct anterior approach in severely obese patients undergoing total hip arthroplasty were comparable to the rates of standard, more extensive approaches, suggesting it might be a credible option with excellent functional and radiographic outcomes [27]. Overall, total hip arthroplasty has a relatively low complication rate [45].

Instability: Successful outcomes in hip arthroscopic surgery for femoroacetabular impingement with capsular management are associated with younger age, normal joint space, and specific preoperative score characteristics [7]. Complete capsular closure in hip arthroscopy restores native anatomy, improves patient-reported outcomes, and reduces complications and revision surgery rates compared to incomplete closure [6].

Other Considerations: Managing borderline dysplasia requires selective management of multiple aspects of hip pathology by an experienced surgeon to optimize outcomes [1]. Arthroscopic reduction in walking-age children with developmental hip dysplasia after failed closed reduction can be performed without post-operative complications over the medium term [2]. Improvements in preoperative workup, imaging, and surgical technique are anticipated to yield continued positive results for hip arthroscopy in older nonarthritic patients [4]. Optimal timing for surgical intervention in the femoroacetabular impingement treatment algorithm remains elusive unless surgical intervention has little effect on the natural history of the diseased hip [9]. Short-term symptomatic relief is possible after revision hip arthroscopy, but further study is required to determine long-term outcomes [15]. Revision total hip arthroplasty using a modular tapered stem with distal fixation did not find an increased number of complications compared to the literature, though further long-term follow-up is essential [18]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis for treatment of focal cartilage defects will maintain structural and functional integrity over time [22]. Additional studies evaluating the long-term outcomes of robotic total hip arthroplasty are needed to determine its long-term advantages [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 [25]. The effect of radiation therapy versus usual care for heterotopic ossification prophylaxis after fixation of acetabular fractures through a posterior approach on functional outcomes remains unclear because surgery to perform heterotopic ossification excision remains exceedingly rare [8]. There is a trend to higher complication rates and the need for further surgery in the treatment of acetabular fractures in patients aged greater than 55 years compared with the results of the treatment of acetabular fractures in younger patients [62]. 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 in mid- to long-term results after bipolar radial head arthroplasty [64].

Recovery

Light activity (weeks): Specific timelines for light activity are not explicitly defined in the provided evidence base; however, patients undergoing preoperative strengthening plus balance training are expected to present similar performance at 1 year postoperatively following total knee replacement [17].

Full activity (months): Significant improvements in quality of life and functional capabilities can be achieved following femoral osteotomy for osteonecrosis of the femoral head, though physical recovery requires an extended duration [38]. Patients with prolonged preoperative symptom duration due to cervical disk herniation demonstrated notable improvements in physical function, disability, pain, and mental health regardless of fusion versus arthroplasty techniques [48]. At a minimum of 5-year follow-up for hip arthroscopy for femoroacetabular impingement syndrome, 82.8% of patients achieved any minimal clinically important difference (MCID), 69.8% achieved any patient acceptable symptom state (PASS), and 58.9% achieved any substantial clinical benefit (SCB) [78].

Complete recovery / outcome plateau (months): At long-term follow-up (sixteen to twenty-two years), patients with a stable thoracolumbar burst fracture treated nonoperatively reported less pain and better function compared with those treated surgically [29]. The ten-year survival rate for the prosthesis as a whole following total hip arthroplasty after operative treatment of an acetabular fracture was 78 percent [79]. Short-term symptomatic relief is possible after revision hip arthroscopy, but further study is required to determine long-term outcomes [15]. 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 [22]. Additional studies evaluating the long-term outcomes of robotic total hip arthroplasty are needed to determine its long-term advantages [23].

Rehabilitation protocol: Optimal timing for surgical intervention in the femoroacetabular impingement treatment algorithm remains elusive, and time is of the essence unless surgical intervention has little effect on the natural history of the diseased hip [9]. Factors associated with successful outcomes in hip arthroscopic surgery for femoroacetabular impingement include younger age, normal joint space, and specific preoperative score characteristics [7]. Revision total hip arthroplasty using a modular tapered stem with distal fixation did not find an increased number of complications compared to the literature, though further long-term follow-up is essential [18].

Functional milestones: The Gluteus-Score-7 predicts the likelihood of both clinical success and failure following surgical repair of the gluteus medius and/or minimus, with 75% of the cohort not undergoing knee arthroplasty within 4 years [76]. Both the direct anterior approach and posterolateral approach for total hip arthroplasty yield good results at an average 5-year follow-up in terms of survivorship, function, rate of complications, and radiographic analysis [30]. 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 [75].

Other Considerations: Arthroscopic reduction in walking-age children with developmental hip dysplasia after failed closed reduction is quick and safe, with no post-operative complications reported over the medium term [2]. Deep wound sepsis occurred in 1.3 percent of hips following total hip arthroplasty, with risk factors including previous operations, prolonged operating time, positive culture at operation, and unrecognized preoperative sepsis [31]. Twenty-seven of twenty-eight hips (96 percent) treated for infection associated with segmental bone loss in the proximal part of the femur in two stages with use of an antibiotic-loaded interval prosthesis had no evidence of infection at the most recent follow-up [77]. The effect of radiation therapy versus usual care for heterotopic ossification prophylaxis after fixation of acetabular fractures on functional outcomes remains unclear because surgery to perform heterotopic ossification excision is exceedingly rare [8].

Key Evidence

  • [L5] The results in this article represent the work of an experienced surgeon selectively managing multiple aspects of hip pathology to optimize outcomes in this defined cohort of patients. (10.2106/jbjs.22.01162)
  • [L4] This method is quick and safe, and it can be performed without post-operative complications over the medium term. (10.1186/s13018-017-0635-7)
  • [L3] Application of these modes to large clinical series will assist in further establishing how to improve the efficacy of these procedures. (10.1302/0301-620x.99b3.bjj-2016-0268.r1)
  • [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)
  • [L5] Complete capsular closure should be embraced as the standard of care, as it restores native anatomy, improves patient-reported outcomes, and reduces complications and revision surgery rates compared to incomplete closure. (10.1016/j.arthro.2024.12.012)
  • [L3] Factors associated with successful outcomes included younger age, normal joint space, and specific preoperative score characteristics. (10.1177/0363546517739824)
  • [L3] However, its effect on functional outcomes remains unclear because surgery to perform heterotopic ossification excision remains exceedingly rare. (10.5435/jaaos-d-24-00491)
  • [Commentary] Optimal timing for surgical intervention in the FAI treatment algorithm remains elusive, and time is indeed of the essence unless surgical intervention has little effect on the natural history of the diseased hip. (10.1016/j.arthro.2020.02.001)
  • [L5] Decision making must be individualized for each patient, and definitive rules regarding management should not be applied to all. (10.1016/j.arthro.2016.06.028)
  • [L4] Ultrasound-guided release of the LSH is a novel surgical option with encouraging results in patients for whom conservative protocols have failed. (10.1186/s13018-021-02461-y)
  • [L3] These subtle differences may have a significant impact when used as indicators of operative success in a population setting. (10.1016/j.arth.2024.01.051)
  • [L3] In clinical practice, however, more attention should be paid to strict compliance to operative indications and the prevention of early complications. (10.1186/s42836-020-00040-w)
  • [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)
  • [L4] Short-term symptomatic relief is possible after revision hip arthroscopy, but further study is required to determine long-term outcomes. (10.1177/0363546507305097)
  • [L4] The findings demonstrate that all patients presented significant mid-term clinical, functional and radiological improvement. (10.1007/s00167-019-05688-9)
  • [L2] Patients are expected to present similar performance at 1 year postoperatively. (10.1007/s00167-020-06029-x)
  • [L3] We did not find an increased number of complications compared to the literature, though further long-term follow-up is essential. (10.1016/j.arth.2008.11.106)
  • [L5] Reaching a consensus on a core outcome set is essential to facilitate data pooling for evidence synthesis and meta-analysis. (10.1302/0301-620x.97b7.35996)
  • [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] These procedures should be performed by surgeons with expertise in advanced arthroscopic techniques, using strict patient selection criteria, with emphasis on labral preservation and capsular plication. (10.1177/0363546517743720)
  • [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)
  • [L3] Additional studies evaluating the long-term outcomes of robotic THA are needed to determine its long-term advantages. (10.5435/jaaos-d-24-01498)
  • [L5] This once-controversial technique has become a standard practice in the field with widespread adoption. (10.1016/j.arthro.2023.07.046)
  • [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] It is recommended only as a salvage measure for severe instability, not as a first-line treatment option. (10.2106/00004623-199804000-00006)
  • [L3] However, these rates were comparable to the rates of the standard, more extensive approaches presented in the literature, suggesting that DAA might be a credible option for obese patients with excellent functional and radiographic outcomes. (10.1016/j.arth.2018.03.071)
  • [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)
  • [L1] While early analysis (four years) revealed few significant differences between the two groups, at long-term follow-up (sixteen to twenty-two years), those with a stable burst fracture who were treated nonoperatively reported less pain and better function compared with those who were treated surgically. (10.2106/jbjs.n.00226)
  • [L1] Both DAA and PA yield good results at an average 5-year follow-up in terms of survivorship, function, rate of complications, and radiographic analysis. (10.1016/j.arth.2019.01.060)
  • [L3] Deep wound sepsis occurred in 1.3 per cent of hips, with risk factors including previous operations, prolonged operating time, positive culture at operation, and unrecognized preoperative sepsis. (10.2106/00004623-197759070-00001)
  • [L3] Female patients showed less favorable clinical outcomes than male patients. (10.1016/j.arthro.2016.01.038)
  • [L4] Prompt surgical treatment with DAIR, following strict diagnostic and therapeutic criteria, in patients with suspected periprosthetic joint infection, can lead to high rates of success in eradicating the infection. (10.1302/0301-620x.99b3.bjj-2016-0609.r1)
  • [L2] Arthroscopic treatment for FAI syndrome yields good patient-reported outcome at the 5-year follow-up. (10.1007/s00167-019-05429-y)
  • [L4] The radiological and preliminary clinical results of this cohort were satisfactory. (10.1302/0301-620x.107b4.bjj-2024-0982.r1)
  • [L3] The treatment of AC as part of hip arthroscopy for labral tear and FAI is safe and has favorable and similar outcomes compared with a control group at minimum 2-year follow-up. (10.1016/j.arthro.2017.10.025)
  • [L3] Significant improvements in quality of life and functional capabilities can be achieved following femoral osteotomy, though physical recovery requires an extended duration. (10.1016/j.arth.2025.06.066)
  • [L5] The authors state that ITB autograft provides a safe and effective technique for labral reconstruction with excellent mid- to long-term outcomes, proven effectiveness, durability, versatility, and limited donor-site morbidity. (10.1016/j.arthro.2023.12.002)
  • [L3] The proposed scoring system may guide decision-making and predict those less likely to have successful outcome with surgical gluteus medius/minimus. (10.1016/j.arthro.2023.08.041)
  • [L3] Variability in resources, procedure volume, operative technique, revision indications, and perioperative prescribing patterns may offer some explanation for this observed discrepancy. (10.1016/j.arth.2024.06.029)
  • [L3] This study demonstrates that the DAA can be safely adopted without significant short-term complication rates for surgeons on the learning curve. (10.1016/j.arth.2018.06.033)
  • [L3] The three salvage procedures produced similar results, however, we recommend the use of PFRA as the complications are less severe. (10.1302/0301-620x.98b1.35202)
  • [L4] Precollapse SIFFH can be treated with bioabsorbable pin stabilization of unstable lesions and treatment of associated intra-capsular pathology in those with stable lesions as determined by a new arthroscopic classification system with promising early outcomes. (10.1007/s00167-017-4722-4)
  • [L3] Overall, THA has a relatively low complication rate. (10.1302/0301-620x.101b6.bjj-2018-1474.r1)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L3] Patients with prolonged preoperative symptom duration due to cervical disk herniation demonstrated notable improvements in physical function, disability, pain, and mental health regardless of fusion versus arthroplasty techniques. (10.5435/jaaos-d-23-00655)
  • [L4] The technique described for stem revision provides reproducibly good results in the treatment of failed osteosynthesis for Vancouver types B1 periprosthetic fractures of the hip. (10.1302/0301-620x.99b4.bjj-2016-1201.r1)
  • [L2] A recent Cochrane analysis did not find arguments in favour of either non-cemented or cemented hemiarthroplasty. (10.1186/1471-2474-10-56)
  • [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] 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] Our results suggest that this procedure is safe and reliable. (10.1186/s42836-022-00159-y)
  • [L5] Evaluation of the patient with recurrent hip instability should be approached systematically with a thorough history and physical examination, along with a focused and targeted radiographic evaluation as indicated. (10.1016/j.arth.2018.01.052)
  • [L4] This versatile technique allows the reconstruction of massive bone defects with relative ease and deserves continued use until longer-term results become available. (10.5435/00124635-199901000-00001)
  • [L2] These results suggest that repair after capsulotomy may be a favorable arthroscopic capsular management technique. (10.1177/0363546519894301)
  • [L4] Surgeons are willing to participate in surgical versus nonsurgical trials with a 6-month crossover endpoint, yet surgeons are reluctant to offer surgical treatment of FAI without correction of osseous deformity, particularly for cam-type pathomorphology. (10.1016/j.arthro.2015.07.003)
  • [L2] Hip arthroscopy in patients with acetabular retroversion resulted in no difference in functional outcomes compared with patients with normal version. (10.2106/jbjs.21.00375)
  • [L3] However, they demonstrate similar MCID achievement and magnitude improvement between preoperative and 5-year postoperative PROs, and return to work without restrictions at a similar rate to non-WC patients, although they may take longer to do so. (10.1016/j.arthro.2023.03.023)
  • [L4] Hip stability was achieved in twenty-three of the twenty-five patients. (10.2106/00004623-197759080-00014)
  • [L4] This study highlights that, of the many forms of treatment available for this group of patients, there is a trend to higher complication rates and the need for further surgery compared with the results of the treatment of acetabular fractures in younger patients. (10.1302/0301-620x.96b2.32979)
  • [L5] The authors argue that current classification of borderline hip dysplasia based solely on lateral center edge angle is insufficient and that the focus must shift to assessing hip instability to better predict treatment outcomes and the need for bony realignment. (10.1016/j.arthro.2023.10.023)
  • [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)
  • [L4] The new method of trochanteric detachment avoids tensile forces and creates compressive forces, which contributes to the quality of bone repair. (10.2106/00004623-197557080-00019)
  • [L4] With excellent functional outcome, custom-made cementless prostheses should be considered as a treatment option for osteoarthritis secondary to Legg-Calve-Perthes disease in the presence of abnormal proximal femoral and acetabular anatomy. (10.1016/j.arth.2013.08.007)
  • [L3] Atypical posterior hip pain is an uncommon presentation of FAI. (10.1177/0363546517692983)
  • [L3] Aligning the stem close to femoral anteversion 10 mm above the lesser trochanter often led to the desired component anteversion. (10.1186/s42836-024-00248-0)
  • [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)
  • [L3] To the authors knowledge this study represents the largest reported cohort of SCP patients, showing a durable treatment option, as 75% of our cohort did not undergo a KA within 4 years. (10.1016/j.arthro.2023.08.042)
  • [L4] Twenty-seven of twenty-eight hips (96 percent) had no evidence of infection at the most recent follow-up. (10.2106/00004623-199801000-00011)
  • [L3] At a minimum of 5-year follow-up, 82.8% of patients achieved any MCID, 69.8% achieved any PASS, and 58.9% achieved any SCB. (10.1177/2325967121s00546)
  • [L3] The ten-year survival rate for the prosthesis as a whole was 78 percent. (10.2106/00004623-199809000-00008)

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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.