Influence of Implant Characteristics on Functional Outcomes After Total Hip Arthroplasty: An Ambispective Observational Study

Influence of Implant Characteristics on Functional Outcomes After Total Hip Arthroplasty: An Ambispective Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Influence of Implant Characteristics on Functional Outcomes After Total Hip Arthroplasty: An Ambispective Observational Study Dixit Gautam, Devinder Kumar, Varsha Patial, Anil Kumar, Rajan Singh, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7546102/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Implant characteristics, such as fixation method, femoral head size, and bearing surface, may influence outcomes after total hip arthroplasty (THA). Data from India regarding their impact on patient-reported outcome measures (PROMs) are limited. Methods An ambispective observational study was conducted on 57 patients (72 hips) who underwent primary THA. Patients were subgrouped by fixation type (cemented vs. uncemented), head size (28 mm vs. 32 mm), and bearing surface (metal-on-polyethylene vs. ceramic-on-polyethylene surface). Outcomes were assessed using the Modified Harris Hip Score (mHHS), Oxford Hip Score (OHS), and Forgotten Joint Score (FJS-12) preoperatively and at serial follow-ups up to one year. Results Uncemented stems showed significantly higher PROMs at one year compared with cemented stems (mHHS: 89.1 vs. 82.2, p < 0.001; OHS: 45.2 vs. 42.7, p = 0.004; FJS-12:82.4 vs. 74.2, p = 0.002). Femoral heads measuring 32 mm were associated with superior FJS-12 scores compared with 28 mm heads (83.1 vs. 76.5, p = 0.031), although differences in mHHS and OHS were not significant. The bearing surface type had no significant impact on the outcomes. The overall complication rate was 16.7%, with dislocations more frequent in smaller head sizes. Conclusion Implant-related factors significantly affect functional outcomes after THA. Uncemented fixation and larger femoral heads were associated with improved PROMs, whereas the bearing surface type had no effect at one year. PROM-based evaluations can guide implant selection and should be incorporated into future multicenter studies in the Indian population. Total hip arthroplasty Implant fixation Femoral head size Bearing surface Patient-reported outcome measures Modified Harris Hip Score Oxford Hip Score Forgotten Joint Score Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Total hip arthroplasty (THA) is one of the most effective surgical procedures in orthopaedics, consistently delivering pain relief and functional restoration across a wide range of hip pathologies [ 1 ]. As the number of procedures continues to rise worldwide, the focus has shifted from implant survival alone to a more nuanced evaluation of patient outcomes, including function, quality of life, and implant-related risk factors [ 1 , 2 ]. Patient-reported outcome measures (PROMs), such as the Oxford Hip Score (OHS) and Forgotten Joint Score (FJS-12), have become essential in this regard. These scores not only quantify pain and function but also reflect joint awareness in daily life, with the FJS-12 demonstrating high validity and responsiveness in both registry and clinical studies [ 3 – 5 ]. Defining patient-acceptable symptom states for these PROMs has enabled the meaningful interpretation of surgical success across diverse populations [ 4 , 5 ]. Despite advances in PROMs, implant-related factors remain critical determinants of THA outcomes. The fixation method—cemented versus uncemented—has long been debated. While registry studies and meta-analyses indicate higher survival and favorable functional outcomes with uncemented fixation in younger, active patients [ 6 , 7 , 8 ], cemented stems may still offer advantages in the elderly or those with osteoporotic bone. Femoral head size is another key variable; larger heads improve stability and reduce dislocation risk but may increase volumetric wear [ 9 – 11 ]. Registry data suggest that differences in survival between 32-mm and 36-mm heads are minimal; however, functional outcomes and dislocation rates can be significantly influenced [ 9 , 11 ]. Similarly, the bearing surface selection continues to evolve. Although metal-on-polyethylene remains the most commonly used articulation, alternative surfaces such as ceramic-on-polyethylene and highly cross-linked polyethylene have been introduced to address concerns regarding wear and osteolysis [ 12 ]. Although the short-term outcomes are comparable, the long-term effect of bearing choice on functional recovery remains a subject of ongoing research. In this context, integrating PROMs with implant-related variables provides an opportunity for a more comprehensive assessment of THA outcomes of THA. Recent studies have highlighted that PROMs, such as the OHS and FJS-12, can sensitively capture differences in patient experiences related to implant choice [ 2 – 4 ]. However, evidence from Indian and South Asian cohorts is scarce. This study aimed to evaluate the influence of implant characteristics—including stem fixation method, femoral head size, and bearing surface type—on functional outcomes measured by the mHHS, OHS, and FJS-12 in an Indian population undergoing THA. Materials and Methods Study design and setting This ambispective observational study was conducted in the Department of Orthopaedics at a tertiary care hospital between January 2019 and March 2021. The study was approved by the Institutional Ethics Committee of Dr. RPGMC (approval no. ECR/866/Rajendra/Inst/HP/2013-RR-2016; dated 09 January 2019). Written informed consent was obtained from all participants prior to enrolment. Participants Fifty-seven patients (72 hips) who underwent primary total hip arthroplasty (THA) for advanced hip disease were included in this study. Indications were avascular necrosis of the femoral head, post-traumatic arthritis, inflammatory arthritis, and primary osteoarthritis. The exclusion criteria were revision THA, pathological fractures, active infection, and incomplete follow-up data. Implant characteristics Patients were sub-grouped according to: Fixation method: cemented vs. uncemented stems. Femoral head size: 28 mm vs. 32 mm. Bearing surface: metal-on-polyethylene vs ceramic-on-polyethylene. Implant selection was based on patient age, bone quality, and surgeon’s preference. Outcome measures Functional outcomes were assessed using three validated patient-reported outcome measures (PROMs). Modified Harris Hip Score (mHHS) [13], Oxford Hip Score (OHS) [14], and Forgotten Joint Score-12 (FJS-12) [15]. These instruments have been extensively validated and are widely used in THA research to assess pain, function, and awareness of the joint. Data collection and follow-up Baseline demographics, comorbidities, operative details, implant characteristics, and postoperative complications were also recorded. PROMs were collected preoperatively and at 6 weeks, 3 months, 6 months, and 1 year. Follow-up assessments were conducted in outpatient clinics by independent observers who were not involved in the surgery. Statistical analysis Data were analyzed using IBM SPSS Statistics version XX (IBM Corp., Armonk, NY, USA). Continuous variables are expressed as mean ± standard deviation (SD). Between-group comparisons were performed using independent t-tests or one-way analysis of variance (ANOVA), where appropriate. Pearson’s correlation coefficient was used to evaluate the relationships between PROMs. Statistical significance was set at p < 0.05. Results Demographics Fifty-seven patients (72 hips) underwent primary THA during the study period. The mean age was 51 years, with the majority in the 41–60 year group, and males outnumbered females by approximately 2.3:1. Most patients presented with avascular necrosis as the primary indication for the surgery. Implant characteristics Implant selection varied among the patients. Most hips (90.3%) received metal-on-polyethylene bearings, while 9.7% had ceramic-on-polyethylene bearings (Figure 1). The fixation was predominantly uncemented (81.9%), with smaller proportions of reverse hybrid (8.4%), hybrid (5.5%), and cemented (4.2%) (Figure 2). The femoral head size distribution showed a preference for 32 mm heads (54.2%), followed by 28 mm (30.6%) and 36 mm (15.3%) heads (Figure 3). Titanium alloy stems (73.6%) were more common than stainless steel stems (26.4%) (Figure 4). Among the uncemented femoral components, 81.5% were fully hydroxyapatite-coated and 18.5% were proximally coated (Figure 5). All stems had a dual taper design. Effect of implant characteristics on functional outcomes\ Significant improvements were observed in all PROMs (mHHS, OHS, and FJS-12) at one year compared to baseline (p<0.001 for each). Subgroup analysis showed the following: Effect of bearing surface on outcomes Comparison between metal-on-polyethylene and ceramic-on-polyethylene bearings showed no statistically significant association with functional outcomes. Both groups achieved comparable improvements in the mHHS (p = 0.684), OHS (p = 0.517), and FJS-12 (p = 0.602) (Table 1). Table 1: Comparison of Functional Scores with type of Bearing Surfaces (N=72) Functional Score MOP COP P v alue mHHS 84.47±5.8 85.71±3.04 0.582 OHS 42.52±3.75 42.42±1.99 0.948 FJS 78.13±9.84 82.53±2.99 0.246 Fixation method: Our study observed that uncemented femoral stems achieved significantly higher functional outcomes at one year compared with cemented and hybrid constructs. The mean postoperative scores were superior in the uncemented group for all PROMs: mHHS (p<0.001), OHS (p<0.001), and FJS-12 (p<0.001) (Table 2). Table 2 : Comparison of Functional Scores with Type of Fixation (n=72) Functional Score Cemented Uncemented Hybrid P value mHHS 72.67±14.64 85.34±4.6 83.8±3.39 <0.001 OHS 35.33±10.99 43.15±2.66 40.9±2.7 <0.001 FJS 64.83±18.68 79.84±8.34 75.15±9.8 0.011 Femoral head size: When comparing head sizes, 32 mm femoral heads demonstrated significantly higher FJS-12 scores than 28 mm heads (p = 0.031). However, no statistically significant association was observed between head size and mHHS (p = 0.206) or OHS (p = 0.265) (Table 3). Table 3: Comparison of Functional Scores with Head Size (n=72 Hips) Functional Score 28 mm 32 mm 36 mm P v alue mHHS 82.86±5.1 85.20±5.7 85.9±5.9 0.206 OHS 41.50±2.85 42.84±3.99 43.36±3.3 0.265 FJS 74.34±9.43 80.9±7.97 78.65±12.2 0.031 Effect of femoral stem material on outcomes Stem material was not significantly associated with postoperative functional outcomes in the present study. Titanium and stainless-steel stems showed comparable mHHS (p = 0.247), OHS (p = 0.473), and FJS-12 (p = 0.310) scores. Effect of stem coating on outcomes The type of hydroxyapatite coating on uncemented stems (fully coated vs. proximally coated) was not significantly associated with functional outcomes. There were no differences in the mHHS (p = 0.984), OHS (p = 0.892), or FJS-12 (p = 0.776) (Table 4). Table 4: Comparison of Functional Scores with Coating (n=72 Hips) Functional Score Proximal Complete P v alue mHHS 85.11±4.63 85.08±3.73 0.984 OHS 43.0±2.54 43.08±3.8 0.892 FJS 79.18±8.23 78.37±11.47 0.776 Complications Twelve hips (16.6%) experienced complications, including dislocation (8.3%), limb length discrepancy >1 cm (6.9%), and superficial infection (1.4%). No implant loosening or early revisions were observed during the study period. Discussion This study evaluated the association between implant-related characteristics and functional outcomes after primary THA. All patients experienced significant improvements in PROMs, including mHHS, OHS, and FJS-12, consistent with previous reports demonstrating that THA provides substantial pain relief and functional restoration [ 1 – 5 ]. The focus of this analysis was to determine whether the fixation type, femoral head size, bearing surface, stem material, or coating influenced early patient-reported outcomes. Uncemented fixation predominated in this series and was associated with significantly higher functional scores than cemented and hybrid constructs. The superiority of uncemented stems in our cohort aligns with registry studies and meta-analyses, suggesting that uncemented fixation offers excellent outcomes in younger and middle-aged patients with good bone stock [ 6 – 8 ]. However, cemented stems continue to show advantages in elderly patients, especially in women with poor bone quality [ 6 , 7 ]. Our findings suggest that uncemented stems may provide enhanced early recovery and joint awareness; however, a longer-term follow-up is necessary to confirm their survival advantage in this setting. We found that head size significantly influenced joint awareness, with 32 mm heads demonstrating higher FJS-12 scores than 28 mm heads, while no significant differences were observed for mHHS or OHS. These results highlight that larger head sizes may improve patient-perceived joint function without necessarily altering pain or mobility. Registry studies have similarly shown that 32 mm heads balance stability and wear, whereas further increases in head size beyond 36 mm do not confer survival benefits and may increase volumetric wear [ 9 , 10 ]. Importantly, in our study, larger heads did not increase the dislocation risk, supporting their selective use as a stability-enhancing measure [ 9 , 11 ]. Both metal-on-polyethylene and ceramic-on-polyethylene bearings produced comparable improvements in PROMs, with no significant differences at one year. This is consistent with prior reviews showing that while ceramic bearings may offer reduced long-term wear, short-term patient-reported outcomes are equivalent [ 12 ]. Given the cost implications, bearing choice should be individualized, especially in younger patients, where implant longevity is a greater concern. We observed no significant association between stem material (titanium vs. stainless steel) and the functional outcomes. Both groups demonstrated comparable results for all PROMs. This finding supports the existing literature suggesting that modern stem metallurgy does not independently determine clinical outcomes, provided that the fixation and implant design are appropriate [ 6 ]. Hence, the choice between titanium and stainless steel stems should be guided more by availability, cost, and surgeon preference than by anticipated functional superiority. Similarly, no significant differences in PROMs were observed between the fully hydroxyapatite-coated and proximally coated uncemented stems. Both coatings provided effective osseointegration and stable fixation, with outcomes consistent with the registry findings [ 6 ]. These results suggest that the distribution of HA coating may not be critical for short-term functional outcomes, although a longer follow-up is required to assess differences in survivorship. Our study reaffirmed the responsiveness of all three PROMs, with strong improvements across the time points. The significant correlations observed among the mHHS, OHS, and FJS-12 validate their concurrent use in assessing outcomes after THA [ 2 – 5 ]. Notably, the FJS-12 is sensitive to head size differences, reflecting its unique ability to capture joint awareness as a dimension of recovery [ 5 ]. The overall complication rate was 16.6%, with dislocation being the most common complication (8.3%). Dislocation is one of the leading causes of early THA failure [ 11 ]. In our cohort, larger head sizes were not associated with a higher dislocation risk, reinforcing the stabilizing effect of heads ≥ 32 mm [ 9 , 11 ]. Limb-length discrepancy was noted in 6.9% of hips, while infection was rare (1.4%). No cases of implant loosening or revision were observed during the follow-up period. Limitations This study had certain limitations. It was conducted at a single center with a modest sample size and relatively short follow-up period, which limits generalizability. The number of cemented and ceramic-on-polyethylene implants was small, which reduced the statistical power for subgroup comparisons. Finally, radiographic outcomes and long-term implant survival were not assessed in this study. Strengths Despite these limitations, this study provides valuable insights into how implant-related variables influence patient-reported outcomes in a real-world clinical setting. By integrating multiple PROMs, we captured a comprehensive picture of recovery, including joint awareness, which is often underreported in THA studies. Conclusion Primary THA led to significant improvements in all functional scores, regardless of implant characteristics. Among the implant-related factors, uncemented fixation was associated with superior PROMs, whereas 32 mm femoral heads yielded better joint awareness than 28 mm femoral heads. Bearing surface type, stem material, and coating did not significantly affect the short-term outcomes. These findings suggest that fixation method and head size may play a more influential role in early patient recovery, whereas other implant choices can be individualized based on surgeon preference, availability, and cost. Declarations Conflict of Interest The authors declare no conflict of interest. Ethical Approval This study was approved by the Institutional Ethics Committee of Dr. Rajendra Prasad Government Medical College (Dr. RPGMC), Kangra at Tanda, Himachal Pradesh, India (registration no. ECR/866/Rajendra/Inst/HP/2013-RR-2016; approval dated 09 January 2019). Informed Consent written Informed consent was obtained from the patients for the publication of clinical details and accompanying images. Author Contribution DG and DK conceptualized and designed the study. DG, RS, and AK were involved in patient recruitment, surgical procedures, and data collection. VP contributed to radiological evaluation and imaging analysis. NK assisted with statistical analysis and literature review. DK and DG drafted the main manuscript text. VP and NK prepared the tables and figures. All authors critically reviewed the manuscript and approved the final version for submission. References Rolfson, O., Kärrholm, J., Dahlberg, L. E., & Garellick, G. (2011). Patient-reported outcomes in the Swedish Hip Arthroplasty Register: results of a nationwide prospective observational study. The Journal of bone and joint surgery. British volume , 93 (7), 867–875. https://doi.org/10.1302/0301-620X.93B7.25737 Clark, S. C., Rudisill, S. S., Reuter, Z. C., Couch, C. G., Taunton, M. J., & Hevesi, M. (2024). 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Questionnaire on the perceptions of patients about total hip replacement. The Journal of bone and joint surgery. British volume , 78 (2), 185–190. Behrend, H., Giesinger, K., Giesinger, J. M., & Kuster, M. S. (2012). The "forgotten joint" as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. The Journal of arthroplasty , 27 (3), 430–436.e1. https://doi.org/10.1016/j.arth.2011.06.035 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 May, 2026 Reviews received at journal 14 Apr, 2026 Reviewers agreed at journal 12 Apr, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviewers invited by journal 15 Sep, 2025 Editor assigned by journal 09 Sep, 2025 Submission checks completed at journal 09 Sep, 2025 First submitted to journal 05 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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15:49:44","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":65286,"visible":true,"origin":"","legend":"","description":"","filename":"9da11907ad264f2fbc6604203d87ca411structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7546102/v1/a0d28a23d48dffbc3763624f.xml"},{"id":92102631,"identity":"13e11e3f-fb1b-46fd-ba3a-20d56d0e4915","added_by":"auto","created_at":"2025-09-24 15:57:44","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72415,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7546102/v1/636e824c508639f0e7e53f03.html"},{"id":92101701,"identity":"48aea55e-cff7-4946-8189-53576aa6b6ee","added_by":"auto","created_at":"2025-09-24 15:49:44","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":65001,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of hips according to the bearing surface type (n=72). The majority of patients received metal-on-polyethylene bearings, whereas ceramic-on-polyethylene bearings were used less frequently.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7546102/v1/e9ffdeef84bda340aacf21cd.jpeg"},{"id":92101690,"identity":"b48240ec-8110-4f26-a8bf-d3f5790dd3fc","added_by":"auto","created_at":"2025-09-24 15:49:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45024,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of hips according to the fixation type (n=72). Uncemented fixation was the most common, followed by reverse hybrid, hybrid, and cemented fixations.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7546102/v1/e685183b40f312cd038b9732.png"},{"id":92102627,"identity":"e6a8bdac-4032-4c76-8b3e-1ecc6efcbb2a","added_by":"auto","created_at":"2025-09-24 15:57:44","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":87662,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of hips according to femoral head size (n=72). The preference order was for 32 mm heads, followed by 28 mm and 36 mm heads.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7546102/v1/951d06a3d4414df1420846be.jpeg"},{"id":92101698,"identity":"9cb1798d-7a97-4cbb-b47e-cdec410d5ffe","added_by":"auto","created_at":"2025-09-24 15:49:44","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":66544,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of femoral component materials (n=72). Titanium alloys were used more frequently than stainless steel.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7546102/v1/7103fcf0fb6e56087efd2bab.png"},{"id":92102976,"identity":"0ddd976c-a733-42be-b1f7-8b961697e1fb","added_by":"auto","created_at":"2025-09-24 16:05:44","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":46432,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of hydroxyapatite coating in uncemented femoral components (n=65). Most were fully coated.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7546102/v1/5334be40d174739ff4b68798.png"},{"id":92189092,"identity":"fa654972-4a5a-4b47-8b4a-390f1890c654","added_by":"auto","created_at":"2025-09-25 14:57:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1143593,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7546102/v1/b30c5fe0-4a6e-4d26-9922-957d4bce4e84.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Influence of Implant Characteristics on Functional Outcomes After Total Hip Arthroplasty: An Ambispective Observational Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal hip arthroplasty (THA) is one of the most effective surgical procedures in orthopaedics, consistently delivering pain relief and functional restoration across a wide range of hip pathologies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As the number of procedures continues to rise worldwide, the focus has shifted from implant survival alone to a more nuanced evaluation of patient outcomes, including function, quality of life, and implant-related risk factors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatient-reported outcome measures (PROMs), such as the Oxford Hip Score (OHS) and Forgotten Joint Score (FJS-12), have become essential in this regard. These scores not only quantify pain and function but also reflect joint awareness in daily life, with the FJS-12 demonstrating high validity and responsiveness in both registry and clinical studies [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Defining patient-acceptable symptom states for these PROMs has enabled the meaningful interpretation of surgical success across diverse populations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite advances in PROMs, implant-related factors remain critical determinants of THA outcomes. The fixation method\u0026mdash;cemented versus uncemented\u0026mdash;has long been debated. While registry studies and meta-analyses indicate higher survival and favorable functional outcomes with uncemented fixation in younger, active patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], cemented stems may still offer advantages in the elderly or those with osteoporotic bone. Femoral head size is another key variable; larger heads improve stability and reduce dislocation risk but may increase volumetric wear [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Registry data suggest that differences in survival between 32-mm and 36-mm heads are minimal; however, functional outcomes and dislocation rates can be significantly influenced [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, the bearing surface selection continues to evolve. Although metal-on-polyethylene remains the most commonly used articulation, alternative surfaces such as ceramic-on-polyethylene and highly cross-linked polyethylene have been introduced to address concerns regarding wear and osteolysis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although the short-term outcomes are comparable, the long-term effect of bearing choice on functional recovery remains a subject of ongoing research.\u003c/p\u003e\u003cp\u003eIn this context, integrating PROMs with implant-related variables provides an opportunity for a more comprehensive assessment of THA outcomes of THA. Recent studies have highlighted that PROMs, such as the OHS and FJS-12, can sensitively capture differences in patient experiences related to implant choice [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, evidence from Indian and South Asian cohorts is scarce.\u003c/p\u003e\u003cp\u003eThis study aimed to evaluate the influence of implant characteristics\u0026mdash;including stem fixation method, femoral head size, and bearing surface type\u0026mdash;on functional outcomes measured by the mHHS, OHS, and FJS-12 in an Indian population undergoing THA.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis ambispective observational study was conducted in the Department of Orthopaedics at a tertiary care hospital between January 2019 and March 2021. The study was approved by the Institutional Ethics Committee of Dr. RPGMC (approval no. ECR/866/Rajendra/Inst/HP/2013-RR-2016; dated 09 January 2019). Written informed consent was obtained from all participants prior to enrolment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFifty-seven patients (72 hips) who underwent primary total hip arthroplasty (THA) for advanced hip disease were included in this study. Indications were avascular necrosis of the femoral head, post-traumatic arthritis, inflammatory arthritis, and primary osteoarthritis. The exclusion criteria were revision THA, pathological fractures, active infection, and incomplete follow-up data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplant characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were sub-grouped according to:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFixation method:\u003c/strong\u003e cemented vs. uncemented stems.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFemoral head size:\u003c/strong\u003e 28 mm vs. 32 mm.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBearing surface:\u003c/strong\u003e metal-on-polyethylene vs ceramic-on-polyethylene.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eImplant selection was based on patient age, bone quality, and surgeon\u0026rsquo;s preference.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunctional outcomes were assessed using three validated patient-reported outcome measures (PROMs).\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eModified Harris Hip Score (mHHS)\u003c/strong\u003e [13],\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eOxford Hip Score (OHS)\u003c/strong\u003e [14], and\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eForgotten Joint Score-12 (FJS-12)\u003c/strong\u003e [15].\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese instruments have been extensively validated and are widely used in THA research to assess pain, function, and awareness of the joint.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline demographics, comorbidities, operative details, implant characteristics, and postoperative complications were also recorded. PROMs were collected preoperatively and at 6 weeks, 3 months, 6 months, and 1 year. Follow-up assessments were conducted in outpatient clinics by independent observers who were not involved in the surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using IBM SPSS Statistics version XX (IBM Corp., Armonk, NY, USA). Continuous variables are expressed as mean \u0026plusmn; standard deviation (SD). Between-group comparisons were performed using independent t-tests or one-way analysis of variance (ANOVA), where appropriate. Pearson\u0026rsquo;s correlation coefficient was used to evaluate the relationships between PROMs. Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Fifty-seven patients (72 hips) underwent primary THA during the study period. The mean age was 51 years, with the majority in the 41\u0026ndash;60 year group, and males outnumbered females by approximately 2.3:1. Most patients presented with avascular necrosis as the primary indication for the surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplant characteristics\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Implant selection varied among the patients. Most hips (90.3%) received metal-on-polyethylene bearings, while 9.7% had ceramic-on-polyethylene bearings (Figure 1).\u003c/p\u003e\n\u003cp\u003eThe fixation was predominantly uncemented (81.9%), with smaller proportions of reverse hybrid (8.4%), hybrid (5.5%), and cemented (4.2%) (Figure 2).\u003c/p\u003e\n\u003cp\u003eThe femoral head size distribution showed a preference for 32 mm heads (54.2%), followed by 28 mm (30.6%) and 36 mm (15.3%) heads (Figure 3).\u003c/p\u003e\n\u003cp\u003eTitanium alloy stems (73.6%) were more common than stainless steel stems (26.4%) (Figure 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the uncemented femoral components, 81.5% were fully hydroxyapatite-coated and 18.5% were proximally coated (Figure 5). All stems had a dual taper design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffect of implant characteristics on functional outcomes\\\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSignificant improvements were observed in all PROMs (mHHS, OHS, and FJS-12) at one year compared to baseline (p\u0026lt;0.001 for each). Subgroup analysis showed the following:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEffect of bearing surface on outcomes\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Comparison between metal-on-polyethylene and ceramic-on-polyethylene bearings showed no statistically significant association with functional outcomes. Both groups achieved comparable improvements in the mHHS (p = 0.684), OHS (p = 0.517), and FJS-12 (p = 0.602) (Table 1).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Comparison of Functional Scores with type of Bearing Surfaces (N=72)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunctional Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMOP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e v\u003cstrong\u003ealue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003emHHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 174px;\"\u003e\n \u003cp\u003e84.47\u0026plusmn;5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 173px;\"\u003e\n \u003cp\u003e85.71\u0026plusmn;3.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e0.582\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eOHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 174px;\"\u003e\n \u003cp\u003e42.52\u0026plusmn;3.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 173px;\"\u003e\n \u003cp\u003e42.42\u0026plusmn;1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e0.948\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eFJS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 174px;\"\u003e\n \u003cp\u003e78.13\u0026plusmn;9.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 173px;\"\u003e\n \u003cp\u003e82.53\u0026plusmn;2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 190px;\"\u003e\n \u003cp\u003e0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFixation method:\u003c/strong\u003e Our study observed that uncemented femoral stems achieved significantly higher functional outcomes at one year compared with cemented and hybrid constructs. The mean postoperative scores were superior in the uncemented group for all PROMs: mHHS (p\u0026lt;0.001), OHS (p\u0026lt;0.001), and FJS-12 (p\u0026lt;0.001) (Table 2).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;Comparison of\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunctional Scores with Type of\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFixation (n=72)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunctional Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCemented\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUncemented\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHybrid\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003emHHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e72.67\u0026plusmn;14.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e85.34\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e83.8\u0026plusmn;3.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eOHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e35.33\u0026plusmn;10.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e43.15\u0026plusmn;2.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e40.9\u0026plusmn;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eFJS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e64.83\u0026plusmn;18.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e79.84\u0026plusmn;8.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e75.15\u0026plusmn;9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFemoral head size:\u003c/strong\u003e When comparing head sizes, 32 mm femoral heads demonstrated significantly higher FJS-12 scores than 28 mm heads (p = 0.031). However, no statistically significant association was observed between head size and mHHS (p = 0.206) or OHS (p = 0.265) (Table 3).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Comparison of Functional Scores with Head Size (n=72 Hips)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"579\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunctional Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e28\u003c/strong\u003e\u0026nbsp; \u0026nbsp;\u003cstrong\u003emm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32\u003c/strong\u003e\u0026nbsp; \u0026nbsp;\u003cstrong\u003emm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e36\u003c/strong\u003e\u0026nbsp; \u003cstrong\u003emm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e v\u003cstrong\u003ealue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003emHHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e82.86\u0026plusmn;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e85.20\u0026plusmn;5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e85.9\u0026plusmn;5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eOHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e41.50\u0026plusmn;2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e42.84\u0026plusmn;3.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e43.36\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eFJS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e74.34\u0026plusmn;9.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e80.9\u0026plusmn;7.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e78.65\u0026plusmn;12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEffect of femoral stem material on outcomes\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Stem material was not significantly associated with postoperative functional outcomes in the present study. Titanium and stainless-steel stems showed comparable mHHS (p = 0.247), OHS (p = 0.473), and FJS-12 (p = 0.310) scores.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEffect of stem coating on outcomes\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The type of hydroxyapatite coating on uncemented stems (fully coated vs. proximally coated) was not significantly associated with functional outcomes. There were no differences in the mHHS (p = 0.984), OHS (p = 0.892), or FJS-12 (p = 0.776) (Table 4).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u003c/strong\u003e \u003cstrong\u003eComparison\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof Functional\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eScores\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ewith\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCoating\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=72\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHips)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunctional Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProximal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplete\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e v\u003cstrong\u003ealue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003emHHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e85.11\u0026plusmn;4.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e85.08\u0026plusmn;3.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e0.984\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eOHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e43.0\u0026plusmn;2.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e43.08\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eFJS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e79.18\u0026plusmn;8.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e78.37\u0026plusmn;11.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155px;\"\u003e\n \u003cp\u003e0.776\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwelve hips (16.6%) experienced complications, including dislocation (8.3%), limb length discrepancy \u0026gt;1 cm (6.9%), and superficial infection (1.4%). No implant loosening or early revisions were observed during the study period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the association between implant-related characteristics and functional outcomes after primary THA. All patients experienced significant improvements in PROMs, including mHHS, OHS, and FJS-12, consistent with previous reports demonstrating that THA provides substantial pain relief and functional restoration [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The focus of this analysis was to determine whether the fixation type, femoral head size, bearing surface, stem material, or coating influenced early patient-reported outcomes.\u003c/p\u003e\u003cp\u003eUncemented fixation predominated in this series and was associated with significantly higher functional scores than cemented and hybrid constructs. The superiority of uncemented stems in our cohort aligns with registry studies and meta-analyses, suggesting that uncemented fixation offers excellent outcomes in younger and middle-aged patients with good bone stock [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, cemented stems continue to show advantages in elderly patients, especially in women with poor bone quality [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our findings suggest that uncemented stems may provide enhanced early recovery and joint awareness; however, a longer-term follow-up is necessary to confirm their survival advantage in this setting.\u003c/p\u003e\u003cp\u003eWe found that head size significantly influenced joint awareness, with 32 mm heads demonstrating higher FJS-12 scores than 28 mm heads, while no significant differences were observed for mHHS or OHS. These results highlight that larger head sizes may improve patient-perceived joint function without necessarily altering pain or mobility. Registry studies have similarly shown that 32 mm heads balance stability and wear, whereas further increases in head size beyond 36 mm do not confer survival benefits and may increase volumetric wear [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Importantly, in our study, larger heads did not increase the dislocation risk, supporting their selective use as a stability-enhancing measure [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBoth metal-on-polyethylene and ceramic-on-polyethylene bearings produced comparable improvements in PROMs, with no significant differences at one year. This is consistent with prior reviews showing that while ceramic bearings may offer reduced long-term wear, short-term patient-reported outcomes are equivalent [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Given the cost implications, bearing choice should be individualized, especially in younger patients, where implant longevity is a greater concern.\u003c/p\u003e\u003cp\u003eWe observed no significant association between stem material (titanium vs. stainless steel) and the functional outcomes. Both groups demonstrated comparable results for all PROMs. This finding supports the existing literature suggesting that modern stem metallurgy does not independently determine clinical outcomes, provided that the fixation and implant design are appropriate [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Hence, the choice between titanium and stainless steel stems should be guided more by availability, cost, and surgeon preference than by anticipated functional superiority.\u003c/p\u003e\u003cp\u003eSimilarly, no significant differences in PROMs were observed between the fully hydroxyapatite-coated and proximally coated uncemented stems. Both coatings provided effective osseointegration and stable fixation, with outcomes consistent with the registry findings [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These results suggest that the distribution of HA coating may not be critical for short-term functional outcomes, although a longer follow-up is required to assess differences in survivorship.\u003c/p\u003e\u003cp\u003eOur study reaffirmed the responsiveness of all three PROMs, with strong improvements across the time points. The significant correlations observed among the mHHS, OHS, and FJS-12 validate their concurrent use in assessing outcomes after THA [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Notably, the FJS-12 is sensitive to head size differences, reflecting its unique ability to capture joint awareness as a dimension of recovery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe overall complication rate was 16.6%, with dislocation being the most common complication (8.3%). Dislocation is one of the leading causes of early THA failure [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our cohort, larger head sizes were not associated with a higher dislocation risk, reinforcing the stabilizing effect of heads\u0026thinsp;\u0026ge;\u0026thinsp;32 mm [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Limb-length discrepancy was noted in 6.9% of hips, while infection was rare (1.4%). No cases of implant loosening or revision were observed during the follow-up period.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study had certain limitations. It was conducted at a single center with a modest sample size and relatively short follow-up period, which limits generalizability. The number of cemented and ceramic-on-polyethylene implants was small, which reduced the statistical power for subgroup comparisons. Finally, radiographic outcomes and long-term implant survival were not assessed in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStrengths\u003c/h2\u003e\u003cp\u003eDespite these limitations, this study provides valuable insights into how implant-related variables influence patient-reported outcomes in a real-world clinical setting. By integrating multiple PROMs, we captured a comprehensive picture of recovery, including joint awareness, which is often underreported in THA studies.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePrimary THA led to significant improvements in all functional scores, regardless of implant characteristics. Among the implant-related factors, uncemented fixation was associated with superior PROMs, whereas 32 mm femoral heads yielded better joint awareness than 28 mm femoral heads. Bearing surface type, stem material, and coating did not significantly affect the short-term outcomes. These findings suggest that fixation method and head size may play a more influential role in early patient recovery, whereas other implant choices can be individualized based on surgeon preference, availability, and cost.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of Interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eEthical Approval\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Institutional Ethics Committee of Dr. Rajendra Prasad Government Medical College (Dr. RPGMC), Kangra at Tanda, Himachal Pradesh, India (registration no. ECR/866/Rajendra/Inst/HP/2013-RR-2016; approval dated 09 January 2019).\u003c/p\u003e\n\u003ch2\u003eInformed Consent\u0026nbsp;written\u003c/h2\u003e\n\u003cp\u003eInformed consent\u0026nbsp;was obtained from the patients for the publication of clinical details and accompanying images.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eDG and DK conceptualized and designed the study. DG, RS, and AK were involved in patient recruitment, surgical procedures, and data collection. VP contributed to radiological evaluation and imaging analysis. NK assisted with statistical analysis and literature review. DK and DG drafted the main manuscript text. VP and NK prepared the tables and figures. All authors critically reviewed the manuscript and approved the final version for submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRolfson, O., K\u0026auml;rrholm, J., Dahlberg, L. E., \u0026amp; Garellick, G. (2011). Patient-reported outcomes in the Swedish Hip Arthroplasty Register: results of a nationwide prospective observational study. \u003cem\u003eThe Journal of bone and joint surgery. British volume\u003c/em\u003e, \u003cem\u003e93\u003c/em\u003e(7), 867\u0026ndash;875. https://doi.org/10.1302/0301-620X.93B7.25737\u003c/li\u003e\n\u003cli\u003eClark, S. C., Rudisill, S. S., Reuter, Z. C., Couch, C. G., Taunton, M. J., \u0026amp; Hevesi, M. (2024). Patient-Reported Outcome Measures After Direct Anterior Total Hip Arthroplasty Are Comparable Between Patients With Rheumatoid Arthritis and Osteoarthritis: A Propensity-Matched Analysis. \u003cem\u003eThe Journal of the American Academy of Orthopaedic Surgeons\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e(12), 637\u0026ndash;643. https://doi.org/10.5435/jaaos-d-24-00656\u003c/li\u003e\n\u003cli\u003eLarsson, A., Rolfson, O., \u0026amp; K\u0026auml;rrholm, J. (2019). Evaluation of Forgotten Joint Score in total hip arthroplasty with Oxford Hip Score as reference standard. \u003cem\u003eActa Orthopaedica\u003c/em\u003e, \u003cem\u003e90\u003c/em\u003e(3), 253\u0026ndash;257. https://doi.org/10.1080/17453674.2019.1599252\u003c/li\u003e\n\u003cli\u003eGalea, V. P., Ingelsrud, L. H., Florissi, I., Shin, D., Bragdon, C. R., Malchau, H., Gromov, K., \u0026amp; Troelsen, A. (2020). Patient-acceptable symptom state for the Oxford Hip Score and Forgotten Joint Score at 3 months, 1 year, and 2 years following total hip arthroplasty: a registry-based study of 597 cases. \u003cem\u003eActa Orthopaedica\u003c/em\u003e, \u003cem\u003e91\u003c/em\u003e(4), 372\u0026ndash;377. https://doi.org/10.1080/17453674.2020.1750877\u003c/li\u003e\n\u003cli\u003eLongo, U. G., De Salvatore, S., Marinis, M. G. D., Marchetti, A., Indiveri, A., Santamaria, G., Denaro, V., Di Naro, C., \u0026amp; Piergentili, I. (2021). Total Hip Arthroplasty: Minimal Clinically Important Difference and Patient Acceptable Symptom State for the Forgotten Joint Score 12. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(5), 2267. https://doi.org/10.3390/ijerph18052267\u003c/li\u003e\n\u003cli\u003eM\u0026auml;kel\u0026auml;, K. T., Matilainen, M., Pulkkinen, P., Fenstad, A. M., Havelin, L., Engesaeter, L., Furnes, O., Pedersen, A. B., Overgaard, S., K\u0026auml;rrholm, J., Malchau, H., Garellick, G., Ranstam, J., \u0026amp; Eskelinen, A. (2014). Failure rate of cemented and uncemented total hip replacements: register study of combined Nordic database of four nations. \u003cem\u003eBMJ (Clinical research ed.)\u003c/em\u003e, \u003cem\u003e348\u003c/em\u003e, f7592. https://doi.org/10.1136/bmj.f7592\u003c/li\u003e\n\u003cli\u003eHailer, N. P., Garellick, G., \u0026amp; K\u0026auml;rrholm, J. (2010). Uncemented and cemented primary total hip arthroplasty in the Swedish Hip Arthroplasty Register. \u003cem\u003eActa orthopaedica\u003c/em\u003e, \u003cem\u003e81\u003c/em\u003e(1), 34\u0026ndash;41. https://doi.org/10.3109/17453671003685400\u003c/li\u003e\n\u003cli\u003eAbdulkarim, A., Ellanti, P., Motterlini, N., Fahey, T., \u0026amp; O\u0026apos;Byrne, J. M. (2013). Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eOrthopedic reviews\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(1), e8. https://doi.org/10.4081/or.2013.e8\u003c/li\u003e\n\u003cli\u003eCross, M. B., Mayman, D. J., \u0026amp; Nam, D. (2012). Ideal Femoral Head Size in Total Hip Arthroplasty Balances Stability and Volumetric Wear. \u003cem\u003eHSS Journal\u0026reg;: The Musculoskeletal Journal of Hospital for Special Surgery\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(3), 270\u0026ndash;274. https://doi.org/10.1007/s11420-012-9287-7\u003c/li\u003e\n\u003cli\u003eTsikandylakis, G., K\u0026auml;rrholm, J., Hailer, N. P., Eskelinen, A., M\u0026auml;kel\u0026auml;, K. T., Hallan, G., Furnes, O. N., Pedersen, A. B., Overgaard, S., \u0026amp; Mohaddes, M. (2018). No Increase in Survival for 36-mm versus 32-mm Femoral Heads in Metal-on-polyethylene THA: A Registry Study. \u003cem\u003eClinical orthopaedics and related research\u003c/em\u003e, \u003cem\u003e476\u003c/em\u003e(12), 2367\u0026ndash;2378. https://doi.org/10.1097/CORR.0000000000000508\u003c/li\u003e\n\u003cli\u003eRegis, D., Cason, M., \u0026amp; Magnan, B. (2024). Dislocation of primary total hip arthroplasty: Analysis of risk factors and preventive options. \u003cem\u003eWorld journal of orthopaedics\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(6), 501\u0026ndash;511. https://doi.org/10.5312/wjo.v15.i6.501\u003c/li\u003e\n\u003cli\u003eGrieco, P. W., Pascal, S., Newman, J. M., Shah, N. V., Stroud, S. G., Sheth, N. P., \u0026amp; Maheshwari, A. V. (2018). New alternate bearing surfaces in total hip arthroplasty: A review of the current literature. \u003cem\u003eJournal of clinical orthopaedics and trauma\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(1), 7-16. https://doi.org/10.1016/j.jcot.2017.10.013\u003c/li\u003e\n\u003cli\u003eHarris W. H. (1969). Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. \u003cem\u003eThe Journal of bone and joint surgery. American volume\u003c/em\u003e, \u003cem\u003e51\u003c/em\u003e(4), 737\u0026ndash;755.\u003c/li\u003e\n\u003cli\u003eDawson, J., Fitzpatrick, R., Carr, A., \u0026amp; Murray, D. (1996). Questionnaire on the perceptions of patients about total hip replacement. \u003cem\u003eThe Journal of bone and joint surgery. British volume\u003c/em\u003e, \u003cem\u003e78\u003c/em\u003e(2), 185\u0026ndash;190.\u003c/li\u003e\n\u003cli\u003eBehrend, H., Giesinger, K., Giesinger, J. M., \u0026amp; Kuster, M. S. (2012). The \u0026quot;forgotten joint\u0026quot; as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. \u003cem\u003eThe Journal of arthroplasty\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(3), 430\u0026ndash;436.e1. https://doi.org/10.1016/j.arth.2011.06.035\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Total hip arthroplasty, Implant fixation, Femoral head size, Bearing surface, Patient-reported outcome measures, Modified Harris Hip Score, Oxford Hip Score, Forgotten Joint Score","lastPublishedDoi":"10.21203/rs.3.rs-7546102/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7546102/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eImplant characteristics, such as fixation method, femoral head size, and bearing surface, may influence outcomes after total hip arthroplasty (THA). Data from India regarding their impact on patient-reported outcome measures (PROMs) are limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eAn ambispective observational study was conducted on 57 patients (72 hips) who underwent primary THA. Patients were subgrouped by fixation type (cemented vs. uncemented), head size (28 mm vs. 32 mm), and bearing surface (metal-on-polyethylene vs. ceramic-on-polyethylene surface). Outcomes were assessed using the Modified Harris Hip Score (mHHS), Oxford Hip Score (OHS), and Forgotten Joint Score (FJS-12) preoperatively and at serial follow-ups up to one year.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eUncemented stems showed significantly higher PROMs at one year compared with cemented stems (mHHS: 89.1 vs. 82.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; OHS: 45.2 vs. 42.7, p\u0026thinsp;=\u0026thinsp;0.004; FJS-12:82.4 vs. 74.2, p\u0026thinsp;=\u0026thinsp;0.002). Femoral heads measuring 32 mm were associated with superior FJS-12 scores compared with 28 mm heads (83.1 vs. 76.5, p\u0026thinsp;=\u0026thinsp;0.031), although differences in mHHS and OHS were not significant. The bearing surface type had no significant impact on the outcomes. The overall complication rate was 16.7%, with dislocations more frequent in smaller head sizes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eImplant-related factors significantly affect functional outcomes after THA. Uncemented fixation and larger femoral heads were associated with improved PROMs, whereas the bearing surface type had no effect at one year. PROM-based evaluations can guide implant selection and should be incorporated into future multicenter studies in the Indian population.\u003c/p\u003e","manuscriptTitle":"Influence of Implant Characteristics on Functional Outcomes After Total Hip Arthroplasty: An Ambispective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-24 15:49:39","doi":"10.21203/rs.3.rs-7546102/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-03T15:17:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T16:17:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173409691970653913042056499560977686020","date":"2026-04-13T03:29:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96892771133634481405321409366590017010","date":"2026-03-19T07:27:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-16T02:52:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T12:06:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T12:05:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-09-05T16:45:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"11b2f995-862c-4629-8ff5-bf55ec296a37","owner":[],"postedDate":"September 24th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-03T15:17:36+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T12:23:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-24 15:49:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7546102","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7546102","identity":"rs-7546102","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}