What Is the Role for Hip Resurfacing Arthroplasty?

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Chapter 86 What Is the Role for Hip Resurfacing Arthroplasty?

A. KURSAT. BARIN, MSc, PETER FARIS, PhD, JAMES. POWELL, MD, FRCSC

Hip resurfacing is a technique that has re-emerged since the late 1990s. Hip resurfacing using different methods of fixation and different bearing surfaces have previously been unsuccessful. The experience with the Wagner resurfacing in the early 1980s was reported by Bell and coauthors1 in their study of implant failures with the Wagner resurfacing. They note that loosening was associated with the development of a membrane at the bone-cement interface. This histologic examination of the membrane demonstrated foreign body response to wear products from the arthroplasty. This suggested that the bearing materials used in this second generation of resurfacing devices was a major factor in the high early failure rate.2

The high volumetric of polyethylene of the earlier designs led several investigators to simultaneously and independently investigate in the early 1990s the use of metal-on-metal (MOM) bearing surfaces.3,4 The bearings designed during the 1990s have proved more durable and are the subject of this review.

Hip resurfacing arthroplasty is an increasingly popular hip arthroplasty option for young, active patients who will likely loosen a conventional total hip replacement (THR) prosthesis. THR has proved to be highly effective in elderly and less active patients, who can expect an implant failure rate less than 10% at 10 years after surgery.5 These excellent results, however, are not observed in younger, more active recipients of THR, who routinely put significant strain on their hip prosthesis during work and recreational pursuits. In these patients, implant failure rates of 25% to 30% have been reported at 15 years.6 This is likely caused by an active lifestyle that contributes to excessive wear, osteolysis, and loosening of the implant.7,8

Modern hip resurfacing offers a more conservative approach to hip arthroplasty in terms of bone stock. With this arthroplasty, MOM bearings are used to resurface the worn surfaces of the hip joint. A femoral component is cemented in the majority of systems in current usage onto the proximal femur, and an uncemented acetabular cup is press-fit into the pelvis. This technique minimizes femoral bone resection and potentially restores normal biomechanics. It is generally believed that, compared with THR, MOM hip resurfacing offers the following advantages:

• Maintenance of normal hip biomechanics
• Better proprioceptive feedback
• Improved wear characteristics with no polyethylene-induced osteolysis
• Reduced risk for dislocation because of a larger femoral head
• Greater levels of postsurgical activity
• The possibility for ease of conversion to THR should the resurfacing implant fail

Despite the promising advantages of hip resurfacing, long-term clinical outcomes and safety profiles are not well understood. This chapter presents a summary of the evidence on the clinical effectiveness and safety of hip resurfacing arthroplasty.

EVIDENCE

Systematic Reviews

At this time, there are two Level IV systematic reviews available on the outcomes of hip resurfacing arthroplasty. The systematic review by Vale and colleagues9 compared the reported outcomes of hip resurfacing with other treatments including THR. This review included 20 articles (1990–2001) that met the inclusion criteria, which included study patients who were active and younger than 65 years, and who would likely outlive a THR. Hip resurfacing revision rates were found to range from 0% to 14% over a 3-year follow-up period compared with THR revision rates of 10% or less over a 10-year period. Furthermore, 91% of patients with hip resurfacing were reported to be pain free at 4-year follow-up evaluation, compared with 84% at 11 years for patients with THRs. Unfortunately, that review was limited to eight case series reports of hip resurfacing outcomes. Hence, no comparative studies were available that directly compared hip resurfacing with THR.

Wyness and researchers10 provide a follow-up systematic review on the effectiveness of hip resurfacing based on studies published before 2002 (Level IV). This review includes data from four hip resurfacing studies, four THR studies, and one watchful waiting study. In addition, the authors include three unpublished hip resurfacing studies supplied from manufacturers for analysis. Unfortunately, similar to Vale and colleagues’9 review, no comparative studies were available to this systematic review. The studies included in this review rate poorly for study description and for controlling bias. Of the hip resurfacing reports, revision rates were between 0% and 14.3% over a follow-up range of 8.3 to 48 months.

Prospective, Randomized Studies

One prospective, randomized, controlled trial (RCT)11 has assessed outcomes after modern hip resurfacing with THR. Howie and coauthors12 also report a hip resurfacing RCT that featured 24 patients 55 years or younger. That study compared the outcomes of 11 patients who randomly received McMinn resurfacing devices with 13 patients with THR. The surgeries were performed between 1993 and 1995, and unlike current hip resurfacing techniques, cement fixation of the acetabular component was used. An extremely high revision rate of 73% was observed in the resurfacing group, which contributed to the abandonment of cement fixation for the acetabular component.

Vendittoli and coworkers’11 RCT compares the clinical outcomes of patients with hip resurfacing (107 hips) with THR (103 hips) over a study period from 2003 to 2006. The average age of the hip resurfacing group (49.1 years; range, 23–64 years) was similar to that of the THR group (50.6 years; range, 24–65 years), although the hip resurfacing group had a lower body mass index (27.2 vs. 29.6) than the THR group. Osteoarthritis was the primary diagnosis for all patients, and outcome measures included the, Western Ontario and McMaster Universities (WOMAC) index, Postel-Merle-d’Aubigne (PMA) functional assessment, and the UCLA activity score. This RCT found that hip resurfacing, compared with THR, took longer operating time (101 vs. 85 min) and resulted in shorter length of hospital stay (5.0 days vs. 6.1 days). At 1-year follow-up examination, WOMAC and PMA scores were similar for both groups, although patients with hip resurfacing had greater average UCLA activity scores. Vendittoli and coworkers11

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