Hip Resurfacing

Author: Daniel Hatch

Topic updated on 05/03/13 11:15am

Introduction

History
- prior versions of resurfacing failed in the past due to
  - larger femoral head on polyethylene -> increased volumetric wear -> high osteolysis rate
- modern resurfacing techniques (approved by FDA in 2006) have made the following changes
  - metal-on-metal components
  - larger femoral head
- there has been a recent increase in popularity of modern techniques, particularly in younger patients, due to less femoral bone resection

Indications

Indications
- patients with advanced arthritis and good proximal femoral bone stock
- three types of patients for whom hip resurfacing is indicated (Amstutz, et al)
  - patients with proximal femoral deformity making total hip arthroplasty difficult
  - patients with high risk of sepsis due to prior infection or immunosuppression
  - patients with a neuromuscular diagnosis
Contraindications
- absolute
  - bone stock deficiency of the femoral head or neck (e.g., cystic degeneration of the femoral head)
  - abnormal acetabular anatomy (small)
- relative
  - coxa vara
    - increased risk for neck fractures
  - significant leg length discrepencies (resurfacing does not allow for leg length corrections)
  - female gender (controversial)

Advantages & Disadvantages

Advantages
- preservation of femoral bone stock
- improved restoration of hip biomechanics with lower risk of limb length discrepancy
- lower dislocation rate
- rapid recovery
- revision is easier than an intremedullary THA
- better stability compared to standard small head (22- to 32-mm) THA
- ability to engage in high demand activities
Disadvantages
- lack of modularity with inability to adjust length or correct offset
- requires larger exposure than conventional THA

Outcomes

variable outcome findings in the literature (79% to 98% success rate)
better results found in patients young, larger males with excellent bone stock treated for osteoarthritis than for dysplasia or osteonecrosis
some case series have shown survival comparable to conventional THA, while others have reported higher rates of early revision
- some products have been removed from the market due to early failure
more recent prospective trials have shown few differences between resurfacing and THA

Complications

Periprosthetic femoral neck fracture
- incidence of 0% to 4% (more common than in THA)
- frequent cause for revision in acute post-operative period (<20 weeks)
- mechanism thought to be related to osteonecrosis
- risk factors:
  - notching of the femoral neck
  - osteoporotic bone
  - large areas of preexisting osteonecrosis
  - femoral neck impingement (from malaligned acetabular component)
  - female sex
  - varus positioning of femoral component
- presents as groin pain
- treatment
  - convert to a THA
Implant loosening (aseptic)
- early loosening of the cemented femoral resurfacing component
Heterotopic ossification
- higher incidence of heterotopic ossification (from wider exposure)
Elevated metal ion levels in blood and urine from metal debris (unknown significance)

Please Rate Educational Value!

4.0

Average 4.0 of 11 Ratings

Qbank (4 Questions)

TAG

(OBQ09.134) An active 40-year-old male undergoes hip surgery for arthritis. A post-operative radiograph is provided in Figure A. Each of the following are complications associated with this procedure EXCEPT: Topic

Review Topic

FIGURES: A

1. Deep vein thrombosis
2. Femoral neck fracture
3. Aseptic loosening
4. Polyethylene debris
5. Dislocation

PREFERRED RESPONSE ▶

DISCUSSION: Modern hip resurfacing implants as shown in Figure A utilize metal-on-metal bearing components, thus polyethylene debris (Answer 4) and its potential subsequent osteolysis is not an option. Hip resurfacing has the potential advantages of preserving proximal femoral bone and providing physiologic stress transfer. Potential disadvantages include the inability to adjust offset and limb-length as readily compared to a conventional total hip arthroplasty. Aseptic loosening of the components can occur and would be an indication for conversion to total hip arthroplasty. Fracture of the femoral neck is the most common complication (0-4%) of hip resurfacing. Resurfacing has a lower incidence of dislocation compared to conventional hip arthroplasty but can still occur. The article by Anglin et al states that implanting the femoral component in 10 degrees of relative valgus and high bone mineral density was correlated with increased load to fracture. Notching of the superior femoral neck is associated with increased fracture risk.

REFERENCES:

1. Hing C, Back D, Shimmin A. Hip resurfacing: indications, results, and conclusions. Instr Course Lect. 2007;56:171-8 PMID:17472305 (Link to Abstract)

2. Anglin C, Masri BA, Tonetti J, Hodgson AJ, Greidanus NV. Hip resurfacing femoral neck fracture influenced by valgus placement. Clin Orthop Relat Res. 2007 Dec;465:71-9 PMID:17589356 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD,

Please Rate Educational Value!

4.0

Average 4.0 of 9 Ratings

TAG

(OBQ07.65) All of the following are absolute or relative contraindication to hip resurfacing arthroplasty EXCEPT? Topic

Review Topic

1. 1.5 cm femoral head bone cysts
2. Acetabular dysplasia
3. Coxa vara
4. Femoral neck bone stock deficiency
5. Age less than 50-years-old

PREFERRED RESPONSE ▶

DISCUSSION: Absolute contraindications for resurfacing include deficiency of femoral head or neck bone stock or a small or bone-deficient acetabulum. As described by Schmalzried et al., relative contraindications including coxa vara, female sex, large bone cysts greater than 1cm, or major osteophytic changes in the head neck junction. Coxa vara specifically has been associated with early failure of hip resurfacing. Gupta et al. performed 3D finite element analysis to predict long term bone density changes after hip resurfacing. They showed concerning long-term regions of strain at the head-neck junction which may predispose patients to late femoral neck fracture after resurfacing. In a retrospective review, Easraugh-Waring et al. evaluated what percentage of young adult patients undergoing a total hip arthroplasty would have been canidates for hip resurfacing and found that in approximately 50%, a hip resurfacing may have been indicated.

REFERENCES:

1. Gupta S, New AM, Taylor M. Bone remodelling inside a cemented resurfaced femoral head. Clin Biomech (Bristol, Avon). 2006 Jul;21(6):594-602. PMID:16542761 (Link to Abstract)

2. Easraugh-Waring SJ, Seenath S, Learmonth DS, Learmonth ID. The practical limitations of resurfacing hip arthroplasty. J Arthroplasty. 2006 Jan;21(1):18-22. PMID:16446181 (Link to Abstract)

3. Schmalzried TP, Silva M, de la Rosa MA, Choi ES, Fowble VA. Optimizing patient selection and outcomes with total hip resurfacing. Clin Orthop Relat Res. 2005 Dec;441:200-4. PMID:16331003 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD,

Please Rate Educational Value!

3.0

Average 3.0 of 7 Ratings

TAG

(OBQ07.181) When discussing metal on metal hip resurfacing versus metal on polyethylene total hip replacement, the surgeon should inform the patient that all of the following are disadvatages of hip resurfacing EXCEPT? Topic

Review Topic

1. Higher dislocation rate
2. Higher periprosthetic fracture rate
3. Increased serum metal ion levels
4. Higher rates of osteonecrosis
5. Larger incision and surgical dissection

PREFERRED RESPONSE ▶

DISCUSSION: Hip resurfacing is associated with higher rates (compared to conventional THA) of AVN, higher serum levels of metal ions, and higher rates of early postoperative fractures, specifically femoral neck fractures. However, the dislocation rate is significantly lower with hip resurfacing due to the larger size of the femoral component and more accurate restoration of anatomic hip biomechanics. Shimmin et al report on hip resurfacing complications, and published dislocation rates are 0.75% at a mean of 3 years’ follow-up. Also, in order to prepare the acetabulum while preserving the femoral head, a more extensive surgical approach and soft tissues releases are required for a resurfacing procedure.

REFERENCES:

1. Shimmin AJ, Bare J, Back DL. Complications associated with hip resurfacing arthroplasty. Orthop Clin North Am. 2005 Apr;36(2):187-93, ix. PMID:15833456 (Link to Abstract)

Question Authors:

Doug Nowak MD, Derek Moore, John Badylak MD,

Please Rate Educational Value!

4.0

Average 4.0 of 8 Ratings

TAG

(OBQ06.204) Which of the following is the most common cause of early revision surgery (<20 weeks) following a hip resurfacing arthroplasty? Topic

Review Topic

1. Periprosthetic fracture
2. Rupture of abductors
3. Dislocation
4. Heterotopic ossification
5. Post-operative stiffness

PREFERRED RESPONSE ▶

DISCUSSION: Periprosthetic fracture, specifically femoral neck fracture, is the most common cause of early revision less than 20 weeks following surgery.

The rate of femoral neck fractures following hip resurfacing varies, but most literature reports a rate of 1%. A majority of these fracture happen in the early post-operative period and are the most frequent cause of revision surgery within several months following surgery. The cause is usually multifactorial, but placing the femoral implant in varus, osteonecrosis, and notching have been proven risk factors for fracture.

Little el al report on 377 patients undergoing hip resurfacing. 13 required revision including 8 for fracture of the femoral neck and 3 for loosening of a component. Evidence of osteonecrosis was seen in two of these cases, leading the authors to believe it may contributed to fracture.

Illustration A shows a comparison of a typical total hip replacement and a hip resurfacing arthroplasty. Illustration B shows notching of the femoral neck, a known cause of femoral neck fracture following hip resurfacing. Illustration C shows a femoral neck fracture in a patient with a hip resurfacing.

Illustrations: A

REFERENCES:

1. Little CP, Ruiz AL, Harding IJ, McLardy-Smith P, Gundle R, Murray DW, Athanasou NA. Osteonecrosis in retrieved femoral heads after failed resurfacing arthroplasty of the hip. J Bone Joint Surg Br. 2005 Mar;87(3):320-3. PMID:15773638 (Link to Abstract)

Question Authors:

Mark Karadsheh MD, John Badylak MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 7 Ratings

Videos

	Anterior approach for a hip resurfacing - Dr. Stefan Kreuzer Recon - Surgical Techniques - Hip Resurfacing Surgical technique of an anterior approach for a hip resurfacing performed by Dr...	5/1/2013 151 views 4
	Femoral Head Resurfacing - Dr. Vijay Bose Recon - Surgical Techniques - Hip Resurfacing This video demonstrated a femoral head resurfacing procedure by Dr. Vijay C Bose...	2/20/2013 97 views 4

See More Videos

Groups

ABOS II: Hip Resurfacing

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Schmalzried TP, Silva M, de la Rosa MA, Choi ES, Fowble VA. Optimizing patient selection and outcomes with total hip resurfacing. Clin Orthop Relat Res. 2005 Dec;441:200-4. PMID:16331003 (Link to Abstract)

Level of Evidence 4 (Case Series)

Easraugh-Waring SJ, Seenath S, Learmonth DS, Learmonth ID. The practical limitations of resurfacing hip arthroplasty. J Arthroplasty. 2006 Jan;21(1):18-22. PMID:16446181 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Anglin C, Masri BA, Tonetti J, Hodgson AJ, Greidanus NV. Hip resurfacing femoral neck fracture influenced by valgus placement. Clin Orthop Relat Res. 2007 Dec;465:71-9 PMID:17589356 (Link to Abstract)
Gupta S, New AM, Taylor M. Bone remodelling inside a cemented resurfaced femoral head. Clin Biomech (Bristol, Avon). 2006 Jul;21(6):594-602. PMID:16542761 (Link to Abstract)
Hing C, Back D, Shimmin A. Hip resurfacing: indications, results, and conclusions. Instr Course Lect. 2007;56:171-8 PMID:17472305 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Little CP, Ruiz AL, Harding IJ, McLardy-Smith P, Gundle R, Murray DW, Athanasou NA. Osteonecrosis in retrieved femoral heads after failed resurfacing arthroplasty of the hip. J Bone Joint Surg Br. 2005 Mar;87(3):320-3. PMID:15773638 (Link to Abstract)
Shimmin AJ, Bare J, Back DL. Complications associated with hip resurfacing arthroplasty. Orthop Clin North Am. 2005 Apr;36(2):187-93, ix. PMID:15833456 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Hip Resurfacing

Qbank (4 Questions)

Question Comments

Question Comments

Question Comments

Question Comments

Videos

Groups

Evidence & References Show References

Topic Comments