Long-term patient expectations following hip resurfacing

Hip resurfacing is not hip replacement. In hip resurfacing the head of the femur is capped (after being trimmed) with a smooth metal covering. The damaged bone and cartilage within the socket is removed and replaced with a metal cup, similar to that in a total hip replacement.

In total hip replacement, not only is the head of the femur replaced, but also the socket in the pelvis (acetabulum). One of the main selling points for hip resurfacing is that it leaves more bone so a hip replacement can be performed later.

The procedure itself has fallen out of popularity among doctors. An October 2023 paper (1) writes: “Hip resurfacing was introduced as a potential alternative to total hip arthroplasty (THA), indicated predominantly for younger, high demand patients. The modern metal-on-metal implant was popularized in the 1990s and early 2000s and promised greater wear resistance. However, its popularity waned due to increased rates of complications related to metal toxicity including pseudo-tumors as well as the recall of many resurfacing implants.”

Does Hip Resurfacing Keep a Younger Patient Active?

Another main selling feature for hip resurfacing as opposed to hip replacement is that studies have shown that it allows the patient to remain more active. However, it is for a limited amount of time. Hip resurfacing has an unknown life span. Thereafter, hip replacement is often necessary.

There can be more issues in relation to the soft tissue needed to stabilize the hip: Doctors in the medical journal Radiographics suggest: “Surgical management for hip disorders should preserve the soft tissue constraints in the hip when possible to maintain normal hip biomechanics.” (2)

This is exactly why we see so many patients after hip surgery. It is too often that the soft tissue that holds the tendons to the bone, or the ligaments that hold the bones to the bones, are compromised. Strengthened ligaments and tendons help hold the hip joint in its proper place, causing less grinding and less bone-on-bone. Restored collagen can help rebuild the cartilage between the pelvis and thighbone, cushioning and relieving the bone-on-bone condition. This is when a consultation for regenerative medicine should be considered—and hopefully prior to rather than after surgery: once a prosthesis has been implanted, it is too late to regenerate tissue.

Many times a patient will come into our office with a stack of MRIs, a post-surgical report, and a promise that they were told that they could resume their running after a hip resurfacing procedure. Unfortunately for them, the surgery did not meet their expectations. Recently published research in the American Journal of Sports Medicine, says “Running is possible after hip resurfacing, and runners can even return to some level of competition, but this short follow-up series of hip resurfacing in athletes should be interpreted with caution regarding implant survival.”(3)

A March 2023 study (4) however found great benefits in hip resurfacing especially when compared to total hip replacement in younger patients. In this study of 776 patients from previously published data, researchers found: “No statistically significant difference was found between resurfacing hip arthroplasty and total hip replacement in terms of complications (12.08% and 16.24%, respectively) and revisions (6.32% and 6.14%, respectively). Both resurfacing hip arthroplasty and total hip replacement provide excellent clinical results in a population of young and active patients.  . . These findings provide evidence concerning the safety and clinical effectiveness of resurfacing hip arthroplasty. Because of its bone-preserving properties, the lack of drawbacks and good outcomes, resurfacing hip arthroplasty appears to be a valid alternative to total hip replacement in young and active patients.

hip resurfacing

Lessen Your Expectations as to physical activity and what sports you can play and at what level – what is the health of your hip?

In the Journal of Bone and Joint Surgery, surgeons warn about sports: “High levels of sporting activities can be detrimental to the long-term success of hip resurfacing devices, independently from other risk factors. Patients seeking hip resurfacing are usually young and should limit their involvement in sports to levels that the implant construct will be able to tolerate.”(5)

A June 2023 study (6) of 217 hip resurfacing arthroplasties showed more favorable results for the active, younger patient. All the patients in this study were under forty years old.

  • Of the 23 females who underwent hip resurfacing arthroplasties, none were revised
  • The most common indication for hip resurfacing arthroplasties was femoroacetabular impingement syndrome (133 patients), and avascular necrosis ( 53 patients).
  • Four hips (1.8%) required reoperation for resection of heterotopic ossification, removal of components for infection, and subsidence with loosening. The overall revision rate was 0.9%.

Conclusion: “For younger patients with higher functional expectations and increased lifetime risk for revision, hip resurfacing arthroplasty is an excellent bone preserving intervention carrying low complication rates, revision rates, and excellent patient outcomes without lifetime restrictions allowing these patients to return to activity and sport. Thus, in younger male patients with end-stage hip disease and higher demands, referral to a high-volume hip resurfacing arthroplasty surgeon should be considered. ”

Return to sports

A June 2023 study (7) assessed collected data from 11 studies comprising 659 patients that showed 90.9%  of patients were able to return to sports by final follow up of 3 years following hip resurfacing arthroplasty. Eighty percent of patients were able to return to sports at 6 to 12 months after hip resurfacing arthroplasty. The findings of this meta-analysis will enable more informed discussions between patients and healthcare professionals about time for return to sports following hip resurfacing arthroplasty.

Long-term outcomes

A January 2024 study (8) looked at the long-term (about 12 year follow up) clinical and radiological results of hip resurfacing procedures in forty-five patients (average age 46) with osteonecrosis of the femoral head. In this group of patients the doctors found hip resurfacing provides “long-term implant survival and excellent clinical outcomes for end-stage osteonecrosis of the femoral head patients with low complication rates. ”

A September 2023 paper (9) however suggested: Long-term results of hip resurfacing for patients with osteonecrosis of the femoral head were very poor, and should not continue to be used.

Metal-on-metal complications

A November 2023 study (10) assessing the standard and possible future material used in hip repair procedures said: “Metals and ceramics fail in most applications owing to stress shielding and the emission of wear debris; ongoing research is being carried out to find a remedy to these unfavorable responses. Recent research found that polymers and composites based on polymers are significant alternative materials for artificial joints. With growing research and several biomaterials, recent reviews lag in effectively addressing hip implant materials’ individual mechanical, tribological, and physiological behaviors.”

Another November 2023 study (11), acknowledging that metal-on-metal hip resurfacing has seen decreased usage due to safety and longevity concerns, especially in females, smaller hips, and hip dysplasia, did suggest that the Birmingham Hip Resurfacing implant showed 100% survivorship in males, exceeding the National Institute for Health and Care Excellence ‘5% at ten years’ threshold.

Are doctors losing interest in the hip resurfacing procedure?

At the beginning of this article I cited an October 2023 study that suggested hip resurfacing procedures, because of long-term complications, had fallen from favor. So has the research surrounding the procedure. The study authors write: “the breadth of literature (medical research) has steadily declined in the past decade, and ultimately demonstrates the decline of scientific interest and focus on novel areas in hip resurfacing and a potential reached consensus.”

References 

1 Shah RV, Ly JA, Magnuson JA, Thompson M, Lorei MP. Hip resurfacing: case closed? A bibliometric analysis of the past 10 years. Archives of Orthopaedic and Trauma Surgery. 2023 Oct 4.
2 Smith MV, Costic RS, Allaire R, Schilling PL, Sekiya JK. A biomechanical analysis of the soft tissue and osseous constraints of the hip joint. Knee Surg Sports Traumatol Arthrosc. 2012 Oct 30.
3 Fouilleron N, Wavreille G, Endjah N, Girard J. Running activity after hip resurfacing arthroplasty: a prospective study. The American journal of sports medicine. 2012 Apr;40(4):889-94.
4 Palazzuolo M, Bensa A, Bauer S, Blakeney WG, Filardo G, Riegger M. Resurfacing Hip Arthroplasty Is a Safe and Effective Alternative to Total Hip Arthroplasty in Young Patients: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2023 Mar 7;12(6):2093.
5 Le Duff MJ, Amstutz HC. The relationship of sporting activity and implant survivorship after hip resurfacing. J Bone Joint Surg Am. 2012 May 16;94(10):911-8.
6 Ramkumar PN, Shaikh HJ, Woo JJ, Haeberle HS, Pang M, Brooks PJ. Hip resurfacing arthroplasty as an alternative to total hip arthroplasty in patients aged under 40 years: a retrospective analysis of 267 hips. Bone & Joint Open. 2023 Jun 1;4(6):408-15.
7 Magan A, Wignadasan W, Kayani B, Radhakrishnan G, Ronca F, Haddad FS. A meta-analysis assessing time for return to sport following hip resurfacing. Archives of orthopaedic and trauma surgery. 2023 Jun;143(6):3575-85.
8 Akçaalan S, Kengil MC, Çağlar C, Uğurlu M. Is there still an indication for the Birmingham Hip Resurfacing in femoral head osteonecrosis? Int Orthop. 2024 Jan 2. doi: 10.1007/s00264-023-06070-8. Epub ahead of print. PMID: 38165447.
9 Hasegawa M, Tone S, Naito Y, Wakabayashi H, Sudo A. Long-term results of hemi-resurfacing and metal-on-metal hip resurfacing for osteonecrosis of the femoral head. Journal of Artificial Organs. 2023 Sep 14:1-7.
10 Sathishkumar S, Paulraj J, Chakraborti P, Muthuraj M. Comprehensive Review on Biomaterials and Their Inherent Behaviors for Hip Repair Applications. ACS Applied Bio Materials. 2023 Oct 23;6(11):4439-64.
11 Ponniah HS, Logishetty K, Edwards TC, Singer GC. Survivorship and risk factors for revision of metal-on-metal hip resurfacing: a long-term follow-up study. Bone & Joint Open. 2023 Nov;4(11):853.

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