Updated: 5/29/2019

Hip Resurfacing

Topic
Review Topic
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Questions
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Evidence
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Videos
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Cases
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https://upload.orthobullets.com/topic/5032/images/xray.hip.ap.shows resurfacing.small.jpg
https://upload.orthobullets.com/topic/5032/images/bhr.jpg
https://upload.orthobullets.com/topic/5032/images/femoral neck fx_moved.jpg
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
    • very popular 10 years ago particularly in younger patients due to less femoral bone resection
Indications
  • Indications (controversial) 
    • patients with advanced arthritis and good proximal femoral bone stock
      • best outcomes in younger males with good bone stock
    • patients with proximal femoral deformity making total hip arthroplasty difficult
  • Contraindications 
    • absolute
      • bone stock deficiency of the femoral head or neck
        • e.g., cystic degeneration of the femoral head
    • relative
      • coxa vara
        • increased risk for neck fractures
      • significant leg length discrepancies
        • resurfacing does not allow leg length corrections
      • female sex of child bearing age (controversial)
        • due to fact that metal ions can cross placenta
      • renal failure
        • functional kidneys required to excrete metal ions
Advantages & Disadvantages
  • Advantages
    • preservation of femoral bone stock
    • better stability compared to standard small head (22- to 32-mm) THA
    • improved restoration of hip biomechanics with lower risk of limb length discrepancy 
    • revision may be easier than an intramedullary THA
  • 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)
    • most common early complication (within first 3 years) and frequent cause for revision in acute post-operative period (<20 weeks)   
    • mechanism thought to be related to osteonecrosis
    • fracture pattern
      • vertical fracture line from neck down to lesser trochanter
    • risk factors
      • femoral neck notching 
        • prevent by placing implant in slight valgus (rather than slight varus)
      • osteoporotic bone
      • large areas of preexisting AVN
      • femoral neck impingement (from malaligned acetabular component)
      • female sex
      • varus positioning of femoral component 
    • presents as groin pain
    • treatment
      • convert to a primary THA
      • place cerclage wire above lesser trochanter to prevent fracture propagation during stem insertion
  • Implant loosening (aseptic) 
    • early loosening of the cemented femoral resurfacing component
  • Heterotopic ossification
    • higher incidence of heterotopic ossification compared to THA (from wider exposure)
  • Metallosis
    • may have elevated metal ion levels (cobalt, chromium, and cobalt-chromium ratio)
    • found in blood and urine from metal debris 
    • presentation and laboratory values may mimic infection
      • may present with elevated synovial WBC due to metal debris and corrosion 
    • most cases related to edge loading of the implant 
  • Dislocation
    • risk is <1% (lower than conventional THA)
  • Pseudotumor
    • risk
      • metal-on-metal implants (like resurfacing)
      • young
      • female sex
    • may be asymptomatic
    • symptomatic patients require revision surgery
 

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Questions (12)
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(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: Review Topic

QID: 2947
FIGURES:
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1

Deep vein thrombosis

3%

(82/2953)

2

Femoral neck fracture

3%

(82/2953)

3

Aseptic loosening

1%

(26/2953)

4

Polyethylene debris

86%

(2529/2953)

5

Dislocation

7%

(219/2953)

L 2

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

QID: 726
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1

1.5 cm femoral head bone cysts

6%

(158/2588)

2

Acetabular dysplasia

4%

(98/2588)

3

Coxa vara

3%

(71/2588)

4

Femoral neck bone stock deficiency

4%

(93/2588)

5

Age less than 50-years-old

84%

(2161/2588)

L 1

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(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 disadvantages of hip resurfacing EXCEPT? Review Topic

QID: 842
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1

Higher dislocation rate

69%

(2151/3138)

2

Higher periprosthetic fracture rate

3%

(85/3138)

3

Increased serum metal ion levels

3%

(100/3138)

4

Higher rates of osteonecrosis

4%

(139/3138)

5

Larger incision and surgical dissection

21%

(649/3138)

L 2

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

QID: 215
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1

Periprosthetic fracture

77%

(1806/2334)

2

Rupture of abductors

1%

(29/2334)

3

Dislocation

14%

(328/2334)

4

Heterotopic ossification

4%

(93/2334)

5

Post-operative stiffness

3%

(65/2334)

L 2

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