Hip resurfacing

Early results from hip resurfacing were variable, partly because of aseptic loosening from poor fixation, and partly because of femoral neck fracture.  In order to conserve bone in the proximal femur, large diameter femoral components are required, with associated large acetabular components.  These can lead to significantly more polyethylene wear with metal-on-plastic (MOP) joints, and metal-on-metal (MOM) have been preferred, but with associated problems with metal ion levels.  In theory better results could be expected from the use of ceramics but this creates difficulties because of the thickness of ceramic material needed.

 There are many more recent reports of individuals returning to high levels of physical activity after hip resurfacing, and the evidence suggests that activities discouraged following total hip arthroplasty are tolerated well by patients after hip resurfacing.  Modern resurfacing performs well in young, active individuals despite high activity levels.  The main findings are that a return to high levels of activity is possible.  It would be reasonable to expect most service personnel, police or firefighters to be able to return to active service after hip resurfacing, but any final decision should depend on the results of rehabilitation and advice from the surgeon.  Provided a good recovery has been achieved, the risk to the joint from high physical activity levels is not substantially increased. More recent developments have improved the technical performance of the components, allowing the biomechanical advantages of resurfacing to be realised.  The result should allow the patient to return to a more active lifestyle. Current devices use a cemented metal femoral component and a cementless metal acetabular component.  Recent studies do show good outcomes including return to high-impact sports, however these so far only cover short to medium term and the evidence-level is low.

A systematic review found little evidence to support resurfacing instead of total arthroplasty, but the main reason for low evidence levels is the lack of randomization (van Gerwen et al., 2010).  Another review showed higher activity levels but higher complication rates after resurfacing (Jiang et al., 2011). 

A recent study of metal-on-metal resurfacing in young patients with osteoarthritis secondary to developmental dysplasia of the hip found an overall survival of 88.2% after a minimum of eight years in patients with an average age of 47.2 years (range 36-64 years). The survival was 91.2% when infectious loosening and failure was excluded (Qu et al., 2014).

A review of 2773 hip resurfacing procedures in Canada with a mean age at operation of 50.5 years found good five-year results in men with a five-year overall survival of 97.4%. Survival in women was 93.6% with higher failure rates where there were smaller femoral components, childhood hip problems and with specific implant types. The conclusion was that hip resurfacing remains justifiable in men, but only in women in exceptional circumstances (2013).

NICE set a benchmark for choosing a total hip replacement at a survival rate of 90% at follow-up of ten years.  A review of metal-on-metal hip resurfacing arthroplasty found a total of 3.5% revised, but many studies were short term.  None met the NICE standard but several studies showed satisfactory survival compared with the NICE three-year benchmark (van der Weegen et al., 2011).

Hemiresurfacing is an option, preserving the acetabulum, but there is no useful evidence in the literature.

2013. The Canadian Arthroplasty Society's experience with hip resurfacing arthroplasty. An analysis of 2773 hips. Bone Joint J, 95-b, 1045-51.

JIANG, Y., ZHANG, K., DIE, J., SHI, Z., ZHAO, H. & WANG, K. 2011. A systematic review of modern metal-on-metal total hip resurfacing vs standard total hip arthroplasty in active young patients. J Arthroplasty, 26, 419-26.

QU, Y., JIANG, T., ZHAO, H., GAO, Y., ZHENG, C. & XU, J. 2014. Mid-term results of metal-on-metal hip resurfacing for treatment of osteoarthritis secondary to developmental dysplasia of the hip: a minimum of 8-years of follow-up. Med Sci Monit, 20, 2363-8.

VAN DER WEEGEN, W., HOEKSTRA, H. J., SIJBESMA, T., BOS, E., SCHEMITSCH, E. H. & POOLMAN, R. W. 2011. Survival of metal-on-metal hip resurfacing arthroplasty: a systematic review of the literature. J Bone Joint Surg Br, 93, 298-306.

VAN GERWEN, M., SHAERF, D. A. & VEEN, R. M. 2010. Hip resurfacing arthroplasty. Acta Orthop, 81, 680-3.