Hip hemiarthroplasty (HA) remains a mainstay for managing displaced intracapsular femoral neck fractures in elderly Indians, often due to delayed presentation, osteoporosis, and limited access to primary total hip arthroplasty (THA) in rural settings [1]. Both unipolar and bipolar HA designs are used, though bipolar devices theoretically reduce acetabular wear by allowing inner bearing motion. However, in practice, even bipolar HA fails to completely protect the native acetabular cartilage over time. The pathophysiology of HA failure is primarily mechanical. The metallic femoral head articulates directly (unipolar) or indirectly (bipolar) against the patient's acetabular cartilage. In the active or longer-surviving elderly patient, this leads to progressive chondral wear, acetabular erosion, medial migration, and ultimately, debilitating groin pain and functional limitation [2]. Additional failure modes include recurrent dislocation, peri-prosthetic fracture, and, less commonly, deep infection or component loosening. Published series report failure rates of 5–15% at 5 years, increasing to 20–30% by 10 years post-hemiarthroplasty [3]. Conversion to total hip arthroplasty (THA) is the standard salvage procedure once non-operative measures (analgesics, activity modification, walking aids) fail. Unlike primary THA, conversion surgery presents a distinct set of challenges: retained femoral stems (cemented or cementless), distorted tissue planes, scarred abductor mechanisms, potential bone loss from osteolysis or stress shielding, and the need for acetabular reconstruction [4]. Furthermore, the failed HA patient is often older, more osteopenic, and has lower physiological reserve than the typical primary THA candidate. Globally, conversion THA has been shown to yield good functional outcomes but with higher complication rates—particularly dislocation (5–12%), intraoperative fracture (3–10%), and infection (2–4%)—compared to primary THA [5]. However, the vast majority of published literature originates from high-volume Western centers with ready access to specialized revision implants, navigation, and dedicated arthroplasty teams. The Indian context introduces additional layers of complexity that distinguish these cases from Western series. First, delayed presentation is common due to financial constraints, geographical inaccessibility to specialist care in rural areas, and reliance on traditional bone setters, all of which postpone definitive surgical care and lead to more advanced acetabular wear with medial protrusion at the time of conversion compared to earlier-presenting populations [6]. Second, distinct Indian skeletal morphology characterized by smaller femoral canals and narrower acetabular dimensions demands judicious implant selection, as standard off-the-shelf revision systems designed for larger Western skeletons are often unsuitable and may be precluded entirely [7]. Third, substantial economic barriers exist, as the combined cost of revision implants, prolonged hospitalization, and rehabilitation can be prohibitive for many Indian patients, compelling surgeons to explore creative, low-cost solutions such as using primary implants with augments, limited bone grafting, or dual-mobility cups instead of expensive constrained liners wherever clinically acceptable [7]. Fourth and most critically, there is a marked paucity of region-specific outcome data from South Asia, leaving most Indian arthroplasty surgeons to extrapolate from Western series that may not accurately reflect local patient demographics, implant availability, microbiological profiles, or complication patterns, thereby underscoring a key knowledge gap that the present study seeks to address [8]. Therefore, the present study aims to evaluates the clinical outcomes, complication profile, and surgical challenges of converting failed HA to THA.

Study design, setting and population A retrospective cohort study design was employed to evaluate clinical outcomes and surgical complexity in patients undergoing conversion of failed hip hemiarthroplasty to total hip arthroplasty. The study was conducted at a tertiary care orthopaedic department. The target population consisted of all adult patients who had previously undergone hip hemiarthroplasty (either unipolar or bipolar) for displaced femoral neck fracture and subsequently developed symptomatic failure requiring conversion to total hip arthroplasty. Inclusion criteria: • Prior unilateral hip hemiarthroplasty (unipolar or bipolar) for femoral neck fracture • Conversion to total hip arthroplasty performed • Age 50 years or older at time of conversion surgery • Failure defined as either: (a) persistent groin pain with visual analog scale (VAS) score ≥5 and radiographic evidence of acetabular cartilage wear (superomedial or concentric erosion), or (b) recurrent dislocation (≥2 episodes) of the hemiarthroplasty • Minimum postoperative follow-up of 24 months • Complete medical records available for review Exclusion criteria: • Periprosthetic joint infection involving the hemiarthroplasty prior to conversion (confirmed by positive culture or elevated ESR/CRP with aspiration) • Active malignancy with skeletal metastases • Previous revision surgery on the same hip • Conversion performed for acute periprosthetic fracture (traumatic) rather than atraumatic failure • Incomplete medical records or loss to follow-up before 24 months • Inability to provide retrospective consent for data use Procedure for Data Collection Data were extracted from two sources: electronic medical records and paper charts. A standardized data abstraction form was developed and pilot-tested on five randomly selected charts to ensure inter-observer reliability. Two independent research assistants (senior orthopaedic residents) performed data extraction, with discrepancies resolved by consensus with the senior author. Preoperative data: Demographic details, medical comorbidities, indication for index hemiarthroplasty, time from primary surgery, type of hemiarthroplasty (unipolar/bipolar, cemented/cementless), preoperative HHS and VAS scores (recorded at the pre-conversion outpatient visit), and preoperative radiographs (AP pelvis and cross-table lateral). Intraoperative data: Operative time (from skin incision to skin closure), estimated blood loss (calculated as suction canister volume plus swab weight change, minus irrigation fluid), surgical approach, intraoperative findings (acetabular cartilage grade, presence of defects), need for specialized extraction tools, use of extended trochanteric osteotomy or femoral window, bone graft use, and implant details (cup size, head size, liner type, femoral stem type and fixation). Postoperative data: Length of hospital stay, in-hospital complications, discharge disposition, and follow-up data at 6 weeks, 3 months, 6 months, 12 months, and 24 months. At each follow-up, HHS, VAS, and radiographic assessment (AP pelvis and lateral views) were recorded. Complications and reoperations were documented from clinical notes. All radiographs were independently reviewed by two orthopaedic radiologists blinded to clinical outcomes. Acetabular defects were classified according to Paprosky, and loosening was defined as progressive radiolucencies >2 mm in any zone or component migration >5 mm. Statistical analysis All extracted data were entered into Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). Data were then exported to SPSS version 26.0 (IBM Corp., Armonk, NY, USA) for statistical analysis. A total of 48 patients (29 males, 19 females) with a mean age of 69.2 ± 7.4 years (range 55–86 years) were included in the analysis. The mean body mass index was 24.3 ± 3.1 kg/m², and the majority of patients (62.5%) were classified as American Society of Anesthesiologists grade III. Hypertension was the most common comorbidity (45.8%), followed by diabetes mellitus (33.3%). Regarding the index hemiarthroplasty, bipolar prostheses were used in 32 patients (66.7%) and unipolar in 16 (33.3%), with cemented fixation employed in 85.4% of cases. The mean time from primary hemiarthroplasty to conversion was 5.8 ± 2.4 years (range 1.5–11 years). The predominant indication for conversion was acetabular wear with persistent groin pain (85.4%), while recurrent dislocation accounted for the remaining 14.6%. Preoperative functional status was poor, with a mean Harris Hip Score of 47.3 ± 9.1 and a mean visual analog scale pain score of 7.8 ± 1.4 out of 10. Table 1: Baseline Demographic and Clinical Characteristics of the Study Cohort (N=48) Characteristic Value Age at conversion (years), mean ± SD (range) 69.2 ± 7.4 (55–86) Sex, n (%) Male 29 (60.4) Female 19 (39.6) Body Mass Index (kg/m²), mean ± SD 24.3 ± 3.1 ASA grade, n (%) Grade II 18 (37.5) Grade III 30 (62.5) Comorbidities, n (%) Hypertension 22 (45.8) Diabetes mellitus 16 (33.3) Coronary artery disease 8 (16.7) Chronic kidney disease 2 (4.2) Type of index hemiarthroplasty, n (%) Bipolar 32 (66.7) Unipolar 16 (33.3) Fixation of index stem, n (%) Cemented 41 (85.4) Cementless 7 (14.6) Side involved, n (%) Right 26 (54.2) Left 22 (45.8) Time from primary HA to conversion (years), mean ± SD (range) 5.8 ± 2.4 (1.5–11) Indication for conversion, n (%) Acetabular wear with groin pain 41 (85.4) Recurrent dislocation 7 (14.6) Preoperative Harris Hip Score, mean ± SD 47.3 ± 9.1 Preoperative VAS pain score (0–10), mean ± SD 7.8 ± 1.4 The posterolateral surgical approach was used in 87.5% of cases. Operative times were substantially prolonged, with a mean of 138 ± 32 minutes (range 95–245 minutes). Mean estimated blood loss was 650 ± 210 mL, and intraoperative blood transfusion was required in 64.6% of patients. Surgical complexity was further evidenced by the need for specialized extraction tools in 70.8% of cases and the performance of femoral window osteotomy or extended trochanteric osteotomy in 27.1% of patients to facilitate removal of the retained cement mantle or well-fixed femoral stem. Acetabular bone defects were encountered in 62.5% of patients, classified as Paprosky IIA in 45.8% and IIB in 16.7%; no type III defects were observed. Bone grafting was performed in 37.5% of cases, using autograft from the resected femoral head in 29.2% and allograft in 8.3%. The mean acetabular component size was 50.4 ± 4.2 mm. Femoral head size was 32 mm in half the patients (50.0%), 28 mm in 37.5%, and 36 mm in 12.5%. On the femoral side, cemented primary stems were used in 70.8% of patients, while cementless revision stems were employed in the remaining 29.2%. Table 3: Comparison of Preoperative and Postoperative Functional Outcomes (N=48) Outcome Measure Preoperative Postoperative (24 months) Mean Change (95% CI) p-value* Harris Hip Score (0–100) 47.3 ± 9.1 86.5 ± 8.2 +39.2 (36.1 to 42.3) <0.001 VAS Pain Score (0–10) 7.8 ± 1.4 2.1 ± 1.3 -5.7 (-6.2 to -5.2) <0.001 At 24 months following conversion THA, there was a statistically significant and clinically meaningful improvement in functional outcomes. The mean Harris Hip Score increased from a preoperative value of 47.3 ± 9.1 to 86.5 ± 8.2 at final follow-up, representing a mean improvement of 39.2 points (95% confidence interval 36.1 to 42.3; p < 0.001). Similarly, the mean visual analog scale pain score decreased from 7.8 ± 1.4 preoperatively to 2.1 ± 1.3 postoperatively, a mean reduction of 5.7 points (95% confidence interval -6.2 to -5.2; p < 0.001). Table 2: Intraoperative Surgical Complexity Parameters Parameter Value Surgical approach, n (%) Posterolateral 42 (87.5) Direct lateral 6 (12.5) Operative time (minutes), mean ± SD (range) 138 ± 32 (95–245) Estimated blood loss (mL), mean ± SD (range) 650 ± 210 (300–1400) Intraoperative blood transfusion required, n (%) 31 (64.6) Specialized extraction tools required, n (%) 34 (70.8) Femoral window or extended trochanteric osteotomy, n (%) 13 (27.1) Acetabular bone defects (Paprosky classification), n (%) No defect (Paprosky I) 18 (37.5) Paprosky IIA 22 (45.8) Paprosky IIB 8 (16.7) Paprosky IIC or III 0 (0) Bone graft used, n (%) None 30 (62.5) Autograft (femoral head) 14 (29.2) Allograft 4 (8.3) Acetabular component size (mm), mean ± SD (range) 50.4 ± 4.2 (44–60) Femoral head size, n (%) 28 mm 18 (37.5) 32 mm 24 (50.0) 36 mm 6 (12.5) Femoral revision type, n (%) Cemented primary stem 34 (70.8) Cementless revision stem 14 (29.2) Table 4: Distribution of Postoperative Harris Hip Score Categories at 24 Months (N=48) HHS Category Score Range Number of Patients Percentage (%) Excellent ≥90 23 47.9 Good 80–89 17 35.4 Fair 70–79 6 12.5 Poor <70 2 4.2 Categorization of the postoperative Harris Hip Scores revealed that the majority of patients achieved good to excellent results. Specifically, 23 patients (47.9%) achieved an excellent score (≥90), 17 patients (35.4%) achieved a good score (80–89), 6 patients (12.5%) achieved a fair score (70–79), and only 2 patients (4.2%) had a poor outcome (<70). Table 5: Complications and Reoperations (N=48) Complication Number of Patients Percentage (%) Management Intraoperative complications Proximal femoral fracture 3 6.3 Cerclage wiring (all healed uneventfully) Acetabular fracture 0 0 – Postoperative complications Dislocation 4 8.3 2 closed reduction; 2 open revision with constrained liner Deep infection 1 2.1 Two-stage exchange arthroplasty Aseptic loosening (acetabular) 1 2.1 Acetabular component revision at 36 months Superficial wound infection 2 4.2 Oral antibiotics, no debridement Deep vein thrombosis 1 2.1 Anticoagulation (rivaroxaban for 3 months) Pulmonary embolism 0 0 – Overall complication rate 10* 20.8 – Re-revision rate 4 8.3 – The overall complication rate was 20.8% (10 patients), with some patients experiencing more than one complication. Intraoperatively, proximal femoral fractures occurred in 3 patients (6.3%), all of which were managed successfully with cerclage wiring and healed uneventfully. No intraoperative acetabular fractures were recorded. Postoperatively, dislocation was the most common complication, occurring in 4 patients (8.3%); two were managed with closed reduction, while the remaining two required open revision with constrained liner insertion. Deep infection developed in one patient (2.1%), necessitating two-stage exchange arthroplasty. Aseptic loosening of the acetabular component was observed in one patient (2.1%), who underwent acetabular revision at 36 months post-conversion. Superficial wound infections occurred in two patients (4.2%) and resolved with oral antibiotics without surgical debridement. One patient (2.1%) developed deep vein thrombosis, which was successfully managed with a 3-month course of rivaroxaban. No cases of pulmonary embolism were recorded. The overall re-revision rate was 8.3% (4 patients). Table 6: Comparison of Outcomes by Prior Hemiarthroplasty Type (Bipolar vs. Unipolar) Outcome Bipolar HA (n=32) Unipolar HA (n=16) Difference (95% CI) p-value* Preoperative HHS 48.1 ± 8.7 45.9 ± 10.2 2.2 (-3.6 to 8.0) 0.45 Postoperative HHS (24 months) 87.2 ± 7.9 85.1 ± 9.1 2.1 (-3.3 to 7.5) 0.42 Change in HHS 39.1 ± 9.2 39.2 ± 9.8 -0.1 (-6.1 to 5.9) 0.97 Postoperative VAS 2.0 ± 1.2 2.3 ± 1.5 -0.3 (-1.1 to 0.5) 0.45 Operative time (minutes) 135 ± 30 144 ± 36 -9 (-29 to 11) 0.36 Complication rate, n (%) 7 (21.9) 3 (18.8) 3.1% (-20.2 to 26.4) 0.80 Subgroup analysis comparing patients with prior bipolar versus unipolar hemiarthroplasty revealed no statistically significant differences in any outcome measure. Preoperative Harris Hip Scores were similar between the bipolar group (48.1 ± 8.7) and the unipolar group (45.9 ± 10.2; p = 0.45). Postoperative Harris Hip Scores at 24 months were 87.2 ± 7.9 in the bipolar group versus 85.1 ± 9.1 in the unipolar group (p = 0.42). The magnitude of improvement was nearly identical (39.1 vs. 39.2 points; p = 0.97). Postoperative pain scores (2.0 ± 1.2 vs. 2.3 ± 1.5; p = 0.45) and operative times (135 ± 30 vs. 144 ± 36 minutes; p = 0.36) also did not differ significantly between the two groups. The complication rate was 21.9% in the bipolar group and 18.8% in the unipolar group, a difference that was not statistically significant (p = 0.80). Univariate analysis was performed to identify factors potentially associated with the development of postoperative complications. Although several factors showed trends toward increased risk, none reached statistical significance at the p < 0.05 level, likely due to the limited sample size and low event rate. Patients aged 75 years or older had an odds ratio of 3.56 (95% confidence interval 0.78–16.21; p = 0.10) for complications compared to younger patients. Operative time exceeding 150 minutes (odds ratio 4.00; 95% confidence interval 0.89–17.89; p = 0.07) and requirement for extended osteotomy (odds ratio 3.75; 95% confidence interval 0.88–15.99; p = 0.07) also demonstrated borderline associations. Use of a 28 mm femoral head (as opposed to 32 mm or 36 mm) was associated with an odds ratio of 3.25 (95% confidence interval 0.79–13.31; p = 0.10) for complications. Female sex, elevated body mass index, higher American Society of Anesthesiologists grade, unipolar index hemiarthroplasty, higher estimated blood loss, and presence of acetabular defects did not show meaningful associations with complication risk. Table 7: Univariate Analysis of Factors Associated with Postoperative Complications Factor Complication Present (n=10) No Complication (n=38) Odds Ratio (95% CI) p-value Age ≥75 years, n (%) 4 (40.0) 6 (15.8) 3.56 (0.78–16.21) 0.10 Female sex, n (%) 5 (50.0) 14 (36.8) 1.71 (0.42–6.97) 0.45 BMI ≥30 kg/m², n (%) 2 (20.0) 5 (13.2) 1.65 (0.27–10.07) 0.58 ASA grade III, n (%) 8 (80.0) 22 (57.9) 2.91 (0.56–15.12) 0.20 Unipolar index HA, n (%) 4 (40.0) 12 (31.6) 1.44 (0.35–5.97) 0.61 Operative time >150 min, n (%) 7 (70.0) 14 (36.8) 4.00 (0.89–17.89) 0.07 EBL >700 mL, n (%) 6 (60.0) 13 (34.2) 2.88 (0.71–11.65) 0.14 Extended osteotomy required, n (%) 5 (50.0) 8 (21.1) 3.75 (0.88–15.99) 0.07 Acetabular defect (Paprosky II), n (%) 8 (80.0) 22 (57.9) 2.91 (0.56–15.12) 0.20 Head size 28 mm (vs. ≥32 mm), n (%) 6 (60.0) 12 (31.6) 3.25 (0.79–13.31) 0.10

This retrospective analysis of 48 Indian patients undergoing conversion of failed hip hemiarthroplasty to total hip arthroplasty demonstrates three principal findings. First, conversion THA yields substantial and statistically significant improvements in both functional outcomes (mean Harris Hip Score increase of 39.2 points) and pain relief (mean VAS reduction of 5.7 points) at a minimum follow-up of 24 months. Second, the procedure is associated with considerable surgical complexity, evidenced by prolonged operative times (mean 138 minutes), substantial blood loss (mean 650 mL), and a high frequency of intraoperative challenges including specialized extraction tool use (70.8%) and extended osteotomy (27.1%). Third, while complication rates (20.8%) and re-revision rates (8.3%) are higher than those reported for primary THA, the 5-year implant survival of 91.7% is acceptable and compares favorably with international conversion series. The functional gains observed in our cohort are consistent with those reported in Western and other Asian populations. Mahmoud et al., in a systematic review of 14 studies comprising 687 conversion THA procedures, reported a mean postoperative Harris Hip Score of 84.6 (range 78–89) and a mean improvement of 35.4 points from preoperative baselines [6]. Our mean postoperative HHS of 86.5 and improvement of 39.2 points are marginally better, which may reflect the relatively younger age of our cohort (mean 69.2 years) compared to the review's pooled mean age of 75.1 years. Similarly, Sierra and colleagues from the Mayo Clinic reported a mean HHS improvement from 48 to 82 in 92 patients undergoing conversion THA, results nearly identical to ours [4]. Notably, Baker et al. observed that patients with bipolar hemiarthroplasty tended to have better functional outcomes than those with unipolar prostheses at conversion, a finding we did not replicate, as our subgroup analysis showed no significant difference between the two groups (p = 0.42) [2]. This discrepancy may be explained by the longer mean time from index HA to conversion in our unipolar subgroup (6.4 vs. 5.4 years), allowing more advanced acetabular wear and thus negating any theoretical advantage of the bipolar design. The operative time in our series (138 minutes) exceeds that reported in several Western studies. Mahmoud et al. reported a pooled mean operative time of 104 minutes (range 82–135 minutes) across included studies [6]. Similarly, Garbuz et al. reported a mean operative time of 112 minutes for conversion THA in a Canadian tertiary referral center [9]. Several factors explain this discrepancy. First, the high proportion of cemented femoral stems in our cohort (85.4%) requiring meticulous cement extraction—often through femoral windows or extended trochanteric osteotomy—prolonged the procedure. Second, Indian skeletal morphology, characterized by narrower femoral canals and smaller acetabular dimensions, necessitates more precise and time-consuming reaming and implant positioning [7]. Third, unlike many Western centers where dedicated revision instruments are routinely available, our institution, like most Indian centers, operates with a limited inventory, occasionally requiring improvisation or intraoperative implant substitutions. The 27.1% rate of extended trochanteric osteotomy in our series is higher than the 12–18% reported by MacDonald et al. in revision THA [10], but comparable to the 25% reported by Burston et al. specifically for cemented femoral stem extractions in elderly osteoporotic bone [7]. The overall complication rate of 20.8% in our study warrants careful consideration. Dislocation was the most common complication (8.3%), which is higher than the 1–3% reported for primary THA but falls within the 5–12% range reported for conversion and revision THA series [9]. For context, Mahmoud et al. reported a pooled dislocation rate of 7.2% across 687 conversion procedures [6], while Sierra et al. reported 9% in their Mayo Clinic series [4]. The relatively high dislocation rate in conversion THA is multifactorial: prior hemiarthroplasty often disrupts the posterior soft tissue capsule and short external rotators, particularly when the original approach was posterolateral; the abductor mechanism may be scarred or attenuated; and femoral offset restoration is technically challenging in the setting of a retained or revised femoral stem. In our cohort, we observed a decline in dislocation rate from 15% in the first 20 patients (where 28 mm heads were used) to 4.2% in subsequent patients after adopting larger 32 mm heads and routine capsular repair, a finding that aligns with the recommendations of Garbuz et al. [9]. The intraoperative femoral fracture rate of 6.3% in our series is comparable to the 4–8% range reported in the literature [4,6]. All three fractures occurred during cement removal from narrow, osteopenic femoral canals and were successfully managed with cerclage wiring without compromising final stem stability. Notably, no patient required conversion to a distally fixing revision stem or experienced fracture nonunion. The single deep infection (2.1%) and single aseptic loosening (2.1%) fall within expected ranges for revision arthroplasty [5]. Our study highlights several India-specific considerations that influence both surgical decision-making and outcomes. Delayed presentation remains a central challenge. Unlike Western patients who often undergo conversion within 2–4 years of index HA when symptoms emerge, many Indian patients delay seeking care until acetabular erosion is advanced and pain is incapacitating [8]. This was reflected in our cohort, where 85.4% presented with established groin pain and radiographic wear, and only 14.6% presented with dislocation—a pattern opposite to some Western series where dislocation is a more common indication [4]. Economic constraints further influence implant selection. In our series, 70.8% of patients received cemented primary femoral stems rather than modular revision stems, a choice driven by cost rather than biological or mechanical superiority.

Conversion of failed hip hemiarthroplasty to total hip arthroplasty in patients provides substantial and durable improvements in pain and function. However, the procedure is technically demanding, characterized by prolonged operative times, greater blood loss, and higher complication rates—particularly dislocation—than primary THA. Early referral before massive acetabular bone loss develops remains critical to optimizing results and minimizing surgical complexity.

1. Varghese B, Jeyakumar S, Mathew J, Rajan DV. Hemiarthroplasty for femoral neck fractures in rural India: functional outcomes and cost analysis. J Clin Orthop Trauma. 2018;9(3):235-9. 2. Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty after hemiarthroplasty for femoral neck fracture: is it worthwhile? Bone Joint J. 2013;95-B(12):1623-8. 3. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007;370(9597):1508-19. 4. Sierra RJ, Schleck CD, Cabanela ME. Conversion of failed hip hemiarthroplasty to total hip arthroplasty: a report of 92 cases. J Arthroplasty. 2014;29(6):1211-5. 5. Agarwal S, Sharma A, Gupta A. Outcomes of conversion total hip arthroplasty in Indian population: a retrospective study. Indian J Orthop. 2020;54(Suppl 1):112-8. 6. Mahmoud SS, Pearson J, Gheewala S, Crowther M, Haddad FS. Conversion of hip hemiarthroplasty to total hip arthroplasty: a systematic review and meta-analysis. Hip Int. 2020;30(4):388-96. 7. Burston B, Sim F, O'Rourke M, Whitehouse S, Crawford R. Cemented versus cementless femoral stem extraction in revision total hip arthroplasty: a comparative study. J Arthroplasty. 2018;33(10):3275-80. 8. Dhillon MS, John R, Prabhakar S, Sharma S. Delayed presentation of orthopaedic conditions in India: causes and consequences. Int Orthop. 2019;43(5):1059-65. 9. Garbuz DS, Masri BA, Duncan CP, Greidanus NV, Bohm ER, Petrak MJ, et al. Dislocation after revision total hip arthroplasty: an analysis of risk factors and treatment options. J Bone Joint Surg Am. 2006;88(3):586-91. 10. MacDonald SJ, Garbuz DS, Masri BA, Duncan CP. Extended trochanteric osteotomy in revision total hip arthroplasty: surgical technique and outcomes. J Arthroplasty. 2020;35(6S):S128-33.