Improved Functional Outcomes of Combined Hip Arthroscopy and Periacetabular Osteotomy at Minimum 2-Year Follow-Up.

PURPOSE: To evaluate patient-reported outcomes (PROs) and survivorship at minimum 2-year follow-up after combined hip arthroscopy and periacetabular osteotomy (PAO) performed in the setting of a single anesthetic event. METHODS: Patients who underwent combined hip arthroscopy (M.J.P.) and PAO (J.M.M.) between January 2017 and June 2020 were identified. Preoperative and minimum 2-year postoperative PROs including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport, modified Harris Hip Score (mHHS), Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form Survey Mental Component Scores (SF-12 MCS), and 12-Item Short Form Survey Physical Component Score were collected and compared in addition to revision rate, conversion to total hip arthroplasty (THA), and patient satisfaction. RESULTS: Twenty-four of 29 patients (83%) eligible for the study were available for 2-year minimum follow-up with a median follow-up time of 2.5 years (range, 2.0-5.0). There were 19 females and 5 males with mean age of 31 ± 12 years. Mean preoperative lateral center edge angle was 20° ± 5° and alpha angle was 71° ± 11°. One patient underwent reoperation for removal of a symptomatic iliac crest screw at 11.7 months after operation. Two patients, a 33-year-old woman and a 37-year-old man, were converted to THA at 2.6 and 1.3 years, respectively, following the combined procedure. Both patients had a Tönnis grade of 1 on radiographs, as well as bipolar Outerbridge grade III/IV defects requiring microfracture of the acetabulum. For patients who did not convert to THA (n = 22), there was significant improvement from before to after surgery for all scores (P < .05) except SF-12 MCS. The minimal clinically significant difference and patient-acceptable symptom state rates for HOS-ADL, HOS-Sport, and mHHS were 72%, 82%, 86%, and 95%, 91%, and 95%, respectively. Median patient satisfaction was 10 (range, 4 to 10). CONCLUSIONS: Single-stage combined hip arthroscopy with periacetabular osteotomy for patients with symptomatic hip dysplasia results in improvement in PROs and arthroplasty free survivorship of 92% at median 2.5 year follow-up. LEVEL OF EVIDENCE: Level IV, case series.

Trans-sacral screw fixation of posterior pelvic ring injuries: review and expert opinion.

Posterior pelvic ring injuries (i.e., sacro-iliac joint dislocations, fracture-dislocations, sacral fractures, pelvic non-unions/malunions) are challenging injury patterns which require a significant level of surgical training and technical expertise. The modality of surgical management depends on the specific injury patterns, including the specific bony fracture pattern, ilio-sacral joint involvement, and the soft tissue injury pattern. The workhorse for posterior pelvic ring stabilization has been cannulated iliosacral screws, however, trans-sacral screws may impart increased fixation strength. Depending on injury pattern and sacral anatomy, trans-sacral screws can potentially be more beneficial than iliosacral screws. In this article, the authors will briefly review pelvic mechanics and discuss their rationale for ilio-sacral and/or trans-sacral screw fixation.

A new understanding of radiographic landmarks of the greater trochanter that indicate correct femoral rotation for measurement of femoral offset.

OBJECTIVES: To establish and validate a novel method for aligning femoral rotation to accurately measure femoral offset for preoperative templating and component sizing, and to identify the physical location of two radiographic lines utilized in the described method. MATERIALS AND METHODS: Cadaveric proximal femurs were skeletonized and mounted to a biaxial load frame. Two radiographic lines along the greater trochanter were identified fluoroscopically. The femurs were rotated, and images were taken when the lines appeared superimposed, then in 2-degree increments to 10° of internal and external rotation, and at 30°. Radiographic femoral offset was calculated at each angle, and the maximum and aligned offsets were compared. Bone was removed until the radiographic lines disappeared, then a metal wire was inserted in place of the bone to confirm that the lines reappeared. RESULTS: The physical locations of the radiographic landmarks were on the anterior and posterior aspects of the greater trochanter. The mean true femoral offset was 38.2 mm (range, 30.5-46.3 mm). The mean aligned femoral offset was 37.3 mm (range, 29.3-46.3 mm), a 2.4% underestimation. The mean angle between aligned and true offset was 3.6° of external rotation (range, 10°ER-8°IR). Intra-rater intraclass correlation coefficient was 0.991. CONCLUSION: Alignment of the radiographic lines created by the anterior and posterior aspects of the greater trochanter is a reliable and accurate rotational positioning method for measuring true femoral offset when using plain films or fluoroscopy, which can aid surgeons with preoperative templating and intraoperative component placement for total hip arthroplasty.

Surgical Treatment of Acetabular Dysplasia With Labral Tears.

Acetabular dysplasia results in abnormal forces across the hip joint and can result in both labral tears and cartilage degeneration. A continuum exists from classic dysplasia to normal acetabular morphology. Diagnosis is aided by several radiographic measurements and parameters including a lateral center edge angle of less than 20°, an anterior center edge angle of less than 20°, a Sharp's angle of greater than 42°, and a Tonnis angle of greater than 10°, or version abnormalities. When patients with acetabular dysplasia present with intra-articular hip pain, skeletal maturity, and preserved radiographic joint space, a periacetabular osteotomy (PAO) is considered as a surgical treatment option when conservative measures have failed. The Bernese PAO was developed in 1984 as a way for reorienting the acetabulum to restore more normal femoral head coverage and orientation. The long-term results of this procedure have been promising with 10-year and 20-year survivorships of approximately 85% and 60%, respectively. When dysplasia is coupled with a labral tear or other intra-articular pathology including focal chondral damage, ligamentum teres tears, or capsular defects, hip arthroscopy and PAO are performed. Although there is a paucity in the literature of the long-term evidence for the combined procedure, early results indicate improved patient reported outcome measures. Appropriate treatment of borderline hip dysplasia remains controversial.

Outcomes after surgical treatment of acetabular fractures: a review.

Acetabular fractures are fractures that extend into the hip joint and pose a challenge for orthopaedic trauma surgeons. The first known descriptions of surgical fixation of acetabular fractures were case reports in 1943. In 1964, Robert Judet, Jean Judet, and Émile Letournel published a landmark article describing a classification system and surgical approaches to treat acetabular fractures. These teachings had a significant effect on clinical outcomes after surgical fixation of acetabular fractures. In 1980, Letournel demonstrated 80% good-to-excellent results in 492 hips, and in 2012, Joel Matta demonstrated 79% survivorship in 816 patients follow surgical acetabular fixation. Both Letournel and Matta have definitively shown that anatomic reduction of the fracture is the most influential factor predictive of clinical outcome. The intent of this review is to summarize the salient factors affecting clinical outcomes after surgical treatment of acetabular fractures.

Ten- and 20-year Survivorship of the Hip After Periacetabular Osteotomy for Acetabular Dysplasia.

INTRODUCTION: Acetabular dysplasia is a multifactorial condition characterized by a shallow hip socket with predisposition to osteoarthritis of the hip. The Bernese periacetabular osteotomy (PAO), developed by Reinhold Ganz in 1984, reorients the dysplastic hip joint to provide more uniform coverage of the femoral head and to extend the longevity of the native hip. Since 1987, the senior author performed the Bernese PAO on more than 430 patients. We performed a cross-sectional retrospective study on this cohort of patients to determine the 10- and 20-year survivorship after PAO in addition to assessing functional outcomes and radiographic parameters. METHODS: Four hundred thirty-four patients were treated for acetabular dysplasia with PAO by the senior surgeon from 1987 to 2014. Data were obtained for 302 hips in 258 patients in a retrospective fashion from medical records and/or mail-in/phone questionnaires. Functional outcome data consisted of postoperative Hip Osteoarthritis Outcome Score and University of California-Los Angeles Activity Score. Pre- and postoperative radiographs were used to determine lateral center-edge angle, anterior center-edge angle, Tönnis angle/grade, and head-to-ilioischial line distance. Survivorship of the native hip was determined by Kaplan-Meier analysis. RESULTS: Of the 302 hips analyzed, 248 were still surviving native hips and 54 had gone on to a total hip arthroplasty (THA) at the time of data acquisition. The average age of patients in the entire cohort at PAO was 32.7 years (range, 13 to 63 years). Of the 258 patients, 215 were female patients (83.3%) and 43 male patients (16.8%). The average age of patients in the surviving group at PAO was 32.3 years, and the average age of patients in the THA group was 36.6 years (P < 0.01). At the time of data acquisition, follow-up ranged from 2 to 27 years (average, 11.2 years). Hip Osteoarthritis Outcome Score and University of California-Los Angeles Activity Score are reported for the surviving native hips after PAO. Radiographic analyses for surviving and failed hips are described, with pre- and postoperative Tönnis grade being statistically significant predictors for conversion to THA (P < 0.01). Survivorship of the native hip was 86% at 10 years and 60% at 20 years in the surviving cohort. Survivorship stratified by age at the time of PAO demonstrated a 10-year survivorship of 93.3%, 90.1%, 81.6%, and 63.2% at ages 20, 30, 40, and 50 years, respectively. No notable difference exists in survivorship between male and female patients; however, male patients had a trend toward lower survivorship compared with female patients at 15 years. CONCLUSION: The 10- and 20-year survivorship of the native hip after PAO is approximately 86% and 60%, respectively, in our cohort of 302 hips. Older age at the time of PAO and higher Tönnis grade are negative prognostic factors for joint survival after PAO. Surviving hips after PAO have good functional outcomes even up to 20 years after surgery. This survivorship analysis represents one of the largest and longest survival studies of patients after PAO, and our results are consistent with other published studies. LEVEL OF EVIDENCE: Level III.

Medical resource utilization and costs for total hip arthroplasty: benchmarking an anterior approach technique in the Medicare population.

AIMS: The anterior approach (AA) for total hip arthroplasty (THA) is associated with more rapid recovery when compared to traditional approaches. The purpose of this study was to benchmark healthcare resource utilization and costs for patients with THA via AA relative to matched patients. MATERIALS AND METHODS: This study queried Medicare claims data (2012-2014) to identify patients who received THA via an AA from experienced surgeons, and matched these patients to a control cohort (all THA approaches). Direct and propensity-score matching were employed to maximize similarity between patients and hospitals in the two cohorts. Hospital length of stay (LOS), the proportion of patients discharged to home or home health, and post-acute claim payments during the 90-day episode were assessed. Generalized estimating equations were applied to control for imbalances between the cohorts and clustering of outcomes within hospitals. RESULTS: A total of 1,794 patients were included after patient matching. Patients who received AA had significantly lower mean hospital LOS vs patients in the control group (2.06 ± 1.36 vs 2.98 ± 1.58 days, p < .0001). The adjusted proportion of patients discharged to home was nearly 20 percentage points higher in the AA cohort vs the control cohort (87.3% vs 68.7%, p < .0001). Post-acute claim payments for AA patients were nearly 50% lower than those for control patients ($4,139 vs $7,465, p < .0001). CONCLUSION: AA patients had significantly lower post-acute care resource use when compared to control patients. Further research is warranted to evaluate the cost effectiveness of AA among surgeons of varying experience levels.

Technical particularities of joint preserving hip surgery in osteopetrosis.

Proximal femoral fracture and coxarthrosis are the most common orthopaedic problems of osteopetrosis. Fracture fixation is difficult and one-third fail, with total hip replacement as the final solution. There is little reported experience about how to deal with this particular type of bone and what has been published to date is surprisingly non-specific. Corrective osteotomies are mainly undertaken in children for non-union of a fractured femoral neck and/or for coxa vara. However, any information about technical problems and solutions is scarce and barely instructive. Osteotomy experience for osteopetrosis in youngsters and young adults has not been reported. Osteopetrosis bone is characterized by a small tolerance for displacement and by the high friction experienced when penetrating instruments and implants are used. This article describes the risks of hip surgery in the presence of osteopetrosis and also discusses osteotomies around the hip and how to limit any related complications. Four patients, who underwent different types of hip preservation procedure, have been used to illustrate the difficulties that can be encountered. The article also suggests ways to make osteotomies feasible in osteopetrosis bone, even in adults.

Chronic Anterior Pelvic Instability: Diagnosis and Management.

Chronic anterior pelvic ring instability can cause pain and disability. Pain typically is localized to the suprapubic area or inner thigh; often is associated with lower back or buttock pain; and may be exacerbated by activity, direct impact, or pelvic ring compression. Known etiologies of chronic anterior pelvic ring instability include pregnancy, parturition, trauma, insufficiency fractures, athletics, prior surgery, and osteitis pubis. Diagnosis often is delayed. Physical examination may reveal an antalgic or waddling gait, tenderness over the pubic bones or symphysis pubis, and pain with provocative maneuvers. AP pelvic radiographs may demonstrate chronic degenerative changes at the pubic symphysis or nonhealing fractures. Standing single leg stance (flamingo view) radiographs can demonstrate pathologic motion at the pubic symphysis. CT may be useful in assessing posterior pelvic ring involvement. The initial management is typically nonsurgical and may include the use of an orthosis, activity modification, medication, and physical therapy. If nonsurgical modalities are unsuccessful, surgery may be warranted, although little evidence exists to guide treatment. Surgical intervention may include internal fixation alone in select patients, the addition of bone graft to fixation, or symphyseal arthrodesis. In some patients, additional stabilization or arthrodesis of the posterior pelvic ring may be indicated.

Is the Anterior Approach Safe? Early Complication Rate Associated With 5090 Consecutive Primary Total Hip Arthroplasty Procedures Performed Using the Anterior Approach.

BACKGROUND: Few publications have raised concern with the safety of the anterior approach (AA) to total hip arthroplasty (THA). The purpose of this study is to report the early complications with AA THA in a combined, multicenter patient population from three different institutions. METHODS: The study cohort consisted of 5090 consecutive primary procedures in 4473 patients who had undergone THA utilizing the anterior approach between August 2006 and July 2013. Surgeries were performed by five surgeons at three sites that maintain prospective databases. Preoperative, intraoperative, and postoperative data were recorded on all patients. Demographic data including age, gender, and BMI were queried, as well as all intraoperative and postoperative complications in the first 90 days. RESULTS: The 5090 patients had a mean body mass index of 27.5, and mean age of 63.6 years. The overall 90-day complication rate was 1.9%. There were 41 intraoperative femur fractures including 29 calcar fractures, 9 greater trochanter fractures and 3 femoral shaft fractures. There were 7 postoperative femur fractures including 3 greater trochanter fractures, 2 calcar fractures, and 2 femur fractures. Other complications included 15 superficial infections, 5 deep infections, 12 dislocations, 8 hematomas, 3 cases of cellulitis, 2 sciatic nerve palsies, 1 peroneal nerve palsy, and intrapelvic bleed. The nonsurgical complication rate was 1.4%. Deep vein thrombosis occurred in 0.3% of cases. CONCLUSION: This large multicenter study of consecutive AA THAs demonstrates an acceptable risk profile within the first 90 days after surgery.

Safe surgical technique: iliac osteotomy via the anterior approach for revision hip arthroplasty.

Robert Judet first performed hip arthroplasty via the anterior approach (AA) in 1947 on an orthopaedic table. Our center has a near 20-year experience on more than 3500 patients operated by AA hip arthroplasty. While primary AA total hip arthroplasty techniques have been discussed in the literature, revision AA total hip arthroplasty techniques are relatively new. The current article in the Journal's "Safe Surgical Technique" series describes the successful application of an adjunctive iliac osteotomy to improve femoral exposure in two selected patients undergoing AA revision hip arthroplasty. The potential risk/complications of an iliac osteotomy include iatrogenic fracture, malunion/nonunion, infection, and pain. These potential risks should be weighed against the potential benefits of improved surgical exposure and/or risks of other revision techniques. Future prospective longitudinal studies will be helpful to determine efficacy and risk profile compared to other revision techniques.

Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures.

BACKGROUND: The aims of the study were (1) to determine the cumulative two to twenty-year survivorship of the hip after open reduction and internal fixation of displaced acetabular fractures, (2) to identify factors predicting conversion to total hip arthroplasty or hip arthrodesis, and (3) to create a predictive model that calculates an individual's probability of early need for total hip arthroplasty or hip arthrodesis. METHODS: Eight hundred and sixteen acetabular fractures treated with open reduction and internal fixation by one surgeon over a twenty-six-year period were analyzed. Cumulative two to twenty-year Kaplan-Meier survivorship analyses of the hip, including best and worst-case scenarios, were performed with total hip arthroplasty or hip arthrodesis as the end point. Univariate and multivariate Cox regression analyses were performed to identify negative predictors, which were then used to construct a nomogram for predicting an individual's probability of needing an early total hip arthroplasty. RESULTS: The cumulative twenty-year survivorship of the 816 hips available for follow-up was 79% at twenty years. The best and worst-case scenarios corresponded to cumulative twenty-year survivorship of 86% and 52%, respectively. Significant independent negative predictors were nonanatomical fracture reduction, an age of more than forty years, anterior hip dislocation, postoperative incongruence of the acetabular roof, involvement of the posterior acetabular wall, acetabular impaction, a femoral head cartilage lesion, initial displacement of the articular surface of ≥ 20 mm, and utilization of the extended iliofemoral approach. CONCLUSIONS: Open reduction and internal fixation of displaced acetabular fractures was able to successfully prevent the need for subsequent total hip arthroplasty within twenty years in 79% of the patients. The results represent benchmark comparative data for any future and past studies on the outcome of surgical fixation of acetabular fractures.

What is the infection rate of the posterior approach to type C pelvic injuries?

BACKGROUND: Pelvic ring injuries with complete disruption of the posterior pelvis (AO/OTA Type C) benefit from reduction and stabilization. Open reduction in early reports had high infectious complications and many surgeons began using closed reduction and percutaneous fixation. Multiple smaller studies have reported low infection rates after a posterior approach, but these rates are not confirmed in larger series of diverse fractures. QUESTIONS/PURPOSES: We therefore determined (1) the incidence of surgical site infectious complications after a posterior approach to the pelvis; and (2) whether secondary procedures other than surgical débridement are necessary as a result of the approach-related complications. METHODS: We retrospectively reviewed all 236 patients (268 surgical approaches) with C type injuries treated with a posterior approach at six institutions before 1998 and at one institution from 1998 to 2005. Posterior injuries were classified anatomically as described by Letournel and the AO/OTA system. We recorded wound complications after surgery. RESULTS: Surgical site infection occurred in eight of the 236 patients (3.4%) in the multicenter analysis. Treatment consisted of surgical débridement, wound closure, and antibiotics. No patients required soft tissue reconstruction as a result of the approach or infection. CONCLUSION: Our data suggest with proper patient selection and the described surgical technique, there should be minimal risk for catastrophic wound complications or high infection rates as reported by others. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Gunshot wounds to the acetabulum.

OBJECTIVES: To classify the fracture patterns of gunshot wounds to the acetabulum; identify the associated injuries and complications; determine the predictors of poor outcome and deep infection; and propose a treatment algorithm based on the results. DESIGN: Retrospective review of two trauma registry databases over a 13-year period. SETTING: Multicenter study. PATIENTS: Thirty-nine gunshot wounds to the acetabulum (38 patients). INTERVENTION: Treatment strategy was based on infection control by treating bowel and bladder injury, presence/absence of intra-articular lead, pattern, and stability of the fracture. MAIN OUTCOME MEASUREMENTS: Merle d'Aubigné score, rate of failures, and complications. Multivariate logistic regression analysis to detect predictors of poor outcome and deep infection. RESULTS: There were 32 simple (82%) and seven (18%) associated fracture patterns. Bowel injuries were the most common associated injures. There was a 54% major complication rate. Significant predictors of poor outcome were high-velocity missile, involvement of the acetabular dome, abdominal injury, nerve injury, vascular injury, and male gender. Significant factors associated with deep infection were presence of a bowel injury with primary anastomosis of the bowel and an associated fracture pattern. CONCLUSIONS: The Letournel classification system can be applied to describe these injuries. The successful treatment of the bowel injury directly correlates to infection control. Diverting colostomy is associated with a reduction of the infection rate. Overall, gunshot wounds to the acetabulum are catastrophic injuries with a high complication rate and poor functional outcome. A multidisciplinary algorithm is proposed for treatment of these complex injuries. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Internal fixation of symphyseal disruption resulting from childbirth.

OBJECTIVES: To investigate the clinical and radiographic results after operative treatment of complete symphyseal disruption resulting from childbirth and to evaluate residual pain and implant failure in relation to the timing of surgery. DESIGN: Retrospective study. SETTING: Tertiary pelvis and acetabulum care unit at a general hospital. PATIENTS: Ten consecutive women with complete symphysis disruption associated with childbirth were included from a database of 603 patients with pelvic fracture. No patients with this diagnosis were excluded. All patients were followed until clinical healing of the symphysis or union of the fusion. INTERVENTION: Open reduction and internal fixation in acute (less than 2 weeks from childbirth, four patients) and after failed nonoperative treatment in subacute cases (2 weeks to 6 months after childbirth, three patients). Fusion of the symphysis with iliac crest bone graft and plate fixation after failed nonoperative treatment in chronic cases (greater than 6 months, three patients). MAIN OUTCOME MEASUREMENT: Analyzed variables included the Lindahl score, maintenance of postoperative reduction, implant failure, malunion, and necessity of reoperation. RESULTS: Mean age of the patients was 32 years (range, 24-37 years). Mean follow up was 29 months (range, 5-139 months). The mean postoperative Lindahl score was 68 ± 14.6 points (range, 38-80 points). There were three excellent, four good, two fair, and one poor result. Fair or poor results occurred in one subacute and two chronic cases. There were two revision surgeries. One patient underwent implant removal resulting from dyspareunia 3.1 years postoperatively. One subacute patient had conversion to symphyseal fusion after implant failure as a result of a fall 11 years after index surgery. Major complications occurred in two and minor complications in three patients. Radiographic loosening of implants was observed in all subacute cases. All fusions healed and symptoms improved at last follow up. CONCLUSIONS: Operative management significantly improved the functional outcomes of all three subgroups and can be an acceptable treatment option for labor-induced complete symphysis pubis disruption.

Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.

The authors conducted a retrospective, multicenter cohort study of 1,152 patients across nine clinical sites across the United States, evaluating complications and function associated with the anterior approach to total hip arthroplasty using an orthopedic table. Eligible patients included those with primary diagnosis of hip arthritis. Outcomes included hospital stay, use of assistive devices, complications, and function. In the cohort of 1,152 patients treated with the anterior approach to total hip arthroplasty, the authors found (i) an acceptable complication profile with a very low dislocation rate, (ii) an early return to function, and (iii) a decline in complications in surgeons with greater than 100 case experiences.

Simultaneous bilateral supine anterior approach total hip arthroplasty: evaluation of early complications and short-term rehabilitation.

Simultaneous bilateral anterior approach total hip arthroplasty has been a successful procedure with high patient demand and good short-term clinical results. Complication rates are acceptable and compare favorably with previously published series. The anterior approach takes advantage of supine positioning, allowing improved intraoperative monitoring and anesthesia care. Short-term rehabilitation goals are met early with this technique. Despite these advantages, providing this simultaneous approach imposes a large financial burden on the hospital and surgeon.

Total hip arthroplasty after periacetabular osteotomy.

Patients with hip dysplasia often endure multiple surgical interventions, first in attempts to preserve their biologic hips and later for total hip arthroplasty (THA). Each different surgical approach traumatizes the musculoligamentous complex of the hip. These cumulative insults can significantly affect THA success. We retrospectively reviewed 8 patients who underwent THA after previous periacetabular osteotomy via the same anterior approach. Acetabular bone stock required no augmentation for implant coverage. No complication occurred during surgery. All patients increased their functional score at last follow-up. No dislocation or implant loosening occurred. Leg-length restoration was excellent. Periacetabular osteotomy is a proven conservative procedure in dysplastic hips that can be realized through a Smith-Petersen incision. Restoration of the acetabular anatomy is achieved with limited muscle detachment. Good results have been achieved with periacetabular osteotomy; however, some patients develop increasing pain from progression of osteoarthritis and require a THA to allow relief of symptoms. The anterior-approach THA is a well-established procedure using the same Smith-Petersen interval as periacetabular osteotomy. Using this approach for both procedures optimizes the patient's immediate and ultimate functional recovery and hip stability. Instead of compromising subsequent THA, periacetabular osteotomy may improve THA results in dysplastic hips.

Multicenter collaboration in observational research: improving generalizability and efficiency.

Utilizing a multicenter approach in observational clinical research allows for improved generalizability of the results, a larger sample size, and, consequently, improved efficiency. This paper highlights important issues with regard to the organization of multicenter observational studies in orthopaedic research. Specifically, we emphasize the development of trial committees, stress the importance of having a methods center for the purpose of coordinating day-to-day study activities, and describe the roles of the participating clinical sites. The successful conduct of multicenter studies requires careful study organization, a dedicated and experienced methods center, and motivated participating surgeons and study staff at the clinical sites. To illustrate the organization of a multicenter initiative, we use the example of a total hip arthroplasty collaborative.