Routine Pathologic Examination of Femoral Heads is Not Warranted

There is significant institutional variation in the practice of routine pathologic examination of femoral heads obtained during primary total hip arthroplasty (THA). In a recent survey of the American Association of Hip and Knee Surgeons, nearly one-third of respondents reported routinely sending femoral heads for pathologic examination, which corresponded to those with an institutional requirement to do so [1]. Pathologic analysis of femoral heads may detect occult disease, such as malignancy. However, the frequency of detection, prognostic significance, and cost of tissue processing and analysis are important considerations.

A systematic review of the literature through 2020 reported routine pathologic examination of femoral head specimens yielded a change in patient management in only 0.0058% of cases [2]. Based on surgeon-reported findings from femoral head pathology, only after 30 years in practice are American Association of Hip and Knee Surgeons members more likely to observe a pathologic diagnosis different from the clinical diagnosis [1]. At an annual cost of up to $63 million in the United States alone, the economic feasibility of routine femoral head pathology, in the face of growing THA prevalence and budgetary constraints, is challenged [2].

Similarly, other groups have concluded that routine femoral head pathology did not benefit patient management in their study cohorts [3,4]. While routine submission of femoral heads for pathologic examination in primary THA is not warranted, surgeons should make the final decision regarding need for pathologic analysis using their relative clinical suspicion on a patient-specific basis.

Conflicts of interest

Brett Levine received royalties from Link; is a paid consultant for Link, Zimmer-Biomet, and Enovis; received royalties, financial or material support from Wolters-Kluwer, Slack Inc., Elsevier, and Human Kinetics; is in the medical/orthopaedic publications editorial/governing board of Journal of Arthroplasty, Orthopedics, and AT (EIC); and is a board member of the AAHKS EBM Committee, AAHKS Member at large, AAOS EQBV Committee, MAOA Education Committee, and Hip/Knee Society Digital Media Committee. Brian Curtin received royalties from Depuy-Synthes; received speakers bureau/paid presentations for Depuy Speakers Board; is a paid consultant for Ethicon, Inc., Zimmer-Biomet, Depuy-Synthes, and Enovis; received research support from Depuy, Stryker, and Zimmer Biomet as a Principal Investigator; received royalties, financial or material support from Springer International Publishing; is in the medical/orthopaedic publications editorial/governing board of Journal of Arthroplasty, CORR, EJOST, and Journal of Orthopedics; and is a board member of the AAHKS Committees. Sumon Nandi received royalties, financial or material support from Springer; is in the medical/orthopaedic publications editorial/governing board of Journal of Arthroplasty, Arthroplasty Today, Journal of Bone and Joint Surgery, and Arthroplasty; and is a board member of AAHKS, AAOS, and Maryland Orthopaedic Association.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2025.101624.