Ethical considerations for multimodal artificial intelligence in healthcare.

Total hip arthroplasty (THA) has become a well-established treatment for femoral neck fractures in elderly patients, offering reliable pain relief, restoration of hip function, and improvement in quality of life (, ). However, age-related reductions in physiological reserve make this population more vulnerable to perioperative blood loss and delays in early recovery (). Excessive blood loss may increase transfusion requirements and perioperative complications, whereas limited early mobilization can hinder rehabilitation and compromise functional outcomes (). Therefore, strategies that reduce perioperative blood loss while facilitating early functional recovery remain clinically important for elderly patients undergoing THA. The posterolateral approach (PLA) remains one of the most commonly used techniques for THA because it offers reliable exposure, clear anatomical planes, and a standardized operative workflow (). Nevertheless, the PLA typically involves a more extensive release of the short external rotator muscles. Even with meticulous repair, native soft-tissue tension and stability may not be fully restored, potentially increasing the risk of postoperative dislocation (1%–3%) (). In addition to its implications for posterior stability, greater posterior muscle injury may increase perioperative blood loss, aggravate postoperative pain, and delay early functional recovery (). The short external rotator muscles are recognized as key contributors to posterior hip integrity and dynamic stability (, ); thus, preserving these structures may promote postoperative recovery. Over the past decade, minimally invasive THA (MIS-THA) has gained increasing interest as a means of reducing surgical morbidity (). Over the past decade, a range of minimally invasive THA techniques (e.g., direct anterior, anterolateral, lateral, and modified posterolateral approaches) have been developed to reduce soft-tissue trauma and facilitate early recovery, although each approach entails distinct trade-offs in exposure, soft-tissue handling, and learning curve (, ). Building on the concept of posterior muscle preservation (, ), Roger and Hill introduced the MIS-TPA, in which only the piriformis tendon is released, while the remaining short external rotators are preserved, and reported lower transfusion rates and faster postoperative recovery in their early experience (). Furthermore, our group previously reported that the MIS-TPA was associated with a milder postoperative inflammatory response than the PLA, reflected by lower levels of muscle injury and inflammatory markers ().