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Orthopedic & Muscular System
Hutt et al., Orthop Muscul Syst 2014, 3:3
http://dx.doi.org/10.4172/2161-0533.1000173
Volume 3 • Issue 3 • 1000173
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
Open Access
Review Article
Total Hip Arthroplasty
versus
Hip Resurfacing: Evidence Based Review and
Current Indications
Jonathan RB Hutt, Martin Lavigne and Pascal-Andre Vendittoli*
Maisonneuve Rosemont Hospital, Montreal University, Canada
Abstract
Total hip arthroplasty (THA) is the gold standard in the treatment of degenerative hip disease, especially in the
older patient. Concerns regarding the higher levels of failure of traditional implants in younger, more active patients
have led to a search for alternative arthroplasty techniques. Hip resurfacing (HR) is one of these alternatives. When
compared with THA, HR has some theoretical advantages that stem from preservation of the patient’s normal proximal
femoral anatomy and the use of a large diameter metal on metal bearing. This has the potential to more accurately
replicate physiological hip function, reduce the risk of dislocation and allow higher levels of activity with minimal wear
of the articulating surface. In addition, the preservation of proximal femoral bone stock offers the potential for easier
revision options as would inevitably be required in younger patients. In order to be considered a suitable alternative,
HR would need to demonstrate improvements or at least equivalence in functional outcomes and survivorship along
with evidence of successful preservation of bone stock leading to good outcomes from future revision surgery. Whilst
the recent expansion of data both in the orthopaedic literature and the mainstream media concerning the potentially
devastating problems from large metal-on-metal (MoM) bearings in some settings carries some salient lessons for both
the development, marketing and uptake of new orthopaedic implants, it should be put in the context of the resurfacing
literature as a whole. In this review we aim to review the current evidence base for HR compared with THA and
examine the current indications for the procedure.
*Corresponding author: Pascal-Andre Vendittoli, Professor of surgery, Montreal
University, Maisonneuve Rosemont Hospital, 5415 boulevard de l’Assomption,
Montreal, Quebec H1T 2M4, Canada, Tel: 514 252-3823, Fax: 514 252-0115;
E-mail: pa.vendittoli@me.com
Received July 30, 2014; Accepted October 31, 2014; Published November 04,
2014
Citation: Hutt JRB, Lavigne M, Vendittoli PA (2014) Total Hip Arthroplasty versus
Hip Resurfacing: Evidence Based Review and Current Indications. Orthop Muscul
Syst 3: 173. doi:10.4172/2161-0533.1000173
Copyright: © 2014 Hutt JRB, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Keywords: Hip; Resurfacing; Arthroplasty; Metal-on-metal;
Evidence-based; Hip replacement
Introduction
Total hip arthroplasty (THA) is the gold standard in the treatment
of degenerative hip disease, especially in the older patient. Concerns
regarding the higher levels of failure of traditional implants in younger,
more active patients [1] have led to a search for alternative arthroplasty
techniques. Hip resurfacing (HR) is one of these alternatives, and
has been around in a recognizable form since the 1970s [2]. When
compared with THA, HR has some theoretical advantages that stem
from preservation of the patient’s normal proximal femoral anatomy
and the use of a large diameter metal on metal bearing. is has the
potential to more accurately replicate physiological hip function,
reduce the risk of dislocation and allow higher levels of activity with
minimal wear of the articulating surface. In addition, the preservation
of proximal femoral bone stock oers the potential for easier revision
options as would inevitably be required in younger patients. In order
to be considered a suitable alternative, HR would need to demonstrate
improvements or at least equivalence in functional outcomes and
survivorship along with evidence of successful preservation of bone
stock leading to good outcomes from future revision surgery. Whilst
the recent expansion of data both in the orthopaedic literature and the
mainstream media concerning the potentially devastating problems
from large metal-on-metal (MoM) bearings in some settings carries
some salient lessons for the development, marketing and uptake
of new orthopaedic implants, it should be put in the context of the
resurfacing literature as a whole. Whilst a systematic review would
allow the formation of more denite conclusions, it is hard to evaluate
more than one or two outcomes. e choice of implant is a signicant
factor in the outcomes of HR especially; the proliferation onto the
market of inferior implants had an eect on available evidence [3,4].
e results from even high quality studies evaluating the results of
recalled or discontinued implants would skew the conclusions. In this
paper we therefore chose to review the broader evidence base for HR
compared with THA covering multiple dierent aspects between the
two procedures. e aim is to provide a comprehensive overview to
help surgeons understand the current areas of controversy.
Methodology
e structure of this article was designed to review the relevant
published evidence for HR and THA under the following sub-sections:
Biomechanics, Clinical Function, Patient Reported Outcomes, Implant
Survivorship, Adverse Events and Implant Revision. Articles for each
section were identied using a broad range of search terms to identify
comparative studies between HR and THA or descriptive studies
for either technique relevant to each section heading. We included
only studies published in the English language aer searching the
MEDLINE, PubMed, EMBASE and Scopus electronic databases. e
numbers and references for each set of articles reviewed for each section
are summarized in Appendix 1. Each has been graded for a level of
evidence according to the system used by the JBJS (Am) since 2003 [5]
Biomechanics
From a biomechanical point of view, the minimal bone resection
on the femoral side and the preservation of proximal femoral anatomy
in HR has the potential to better replicate the normal hip physiology of
the patient (Figure 1). Although accurate pre-operative templating may
reduce inaccuracies in oset and leg length in THA, inevitably the ability
to completely restore these factors will be limited by the modularity
and exibility of the implant system used. Two retrospective studies
by Ahmed et al and Silva et al demonstrated that HR more accurately
Citation: Hutt JRB, Lavigne M, Vendittoli PA (2014) Total Hip Arthroplasty versus Hip Resurfacing: Evidence Based Review and Current Indications.
Orthop Muscul Syst 3: 173. doi:10.4172/2161-0533.1000173
Page 2 of 6
Volume 3 • Issue 3 • 1000173
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
of HR patients and large diameter THRs [23,24]. A recent pragmatic
randomized trial by Costa el al. showed no dierence in clinical
function at 12 months between hip resurfacings and standard THRs
[25]. Penny et al. reported on their randomized trial at 2yrs follow-
up, again demonstrating no signicant dierences in clinical function
scores, UCLA or EQ-5D scores [26]. e longest running randomized
trial by Vendittoli et al. recently published follow-up of 6 to 9 years
and did not nd any signicant dierences in clinical function scores,
although patients in their HR group did demonstrate signicantly
higher UCLA activity scores 5 years aer surgery [15].
Implant survivorship
One proposed advantage of HR is the potential longevity aorded
by reliable modern implant xation and the minimal wear properties
of a metal on metal bearing. Overall, registry data demonstrates
poorer results when HR is used in wider populations. e UK registry
has a revision rate of 12% at 9 years for all HR procedures, and the
Australian registry has 11% revision at 12 years. ere are a number
of confounding factors here. Many dierent companies developed
resurfacing products aer initial promising results from other
designs, but with varying success. e same UK registry report has a
revision rate for the now recalled ASR component at 36% at 9 years
and problems with this particular prosthesis are reported by multiple
authors in the literature [27-29]. Revision rates for HR in the setting
of these problems and their appearance in the mainstream media and
in large scale legal battles may well escalate further as the threshold
for revision is likely to decrease in the light of the potential concerns
regarding metal debris and the consequences of abnormal high wear.
is factor should be taken into account when looking at registry and
other data that is not implant specic, as the inclusion of dis-continued
devices may skew the interpretation. is fact is well demonstrated in a
recent systematic review of outcomes, where the authors demonstrated
that revisions and re-operations were more frequent for HR, unless
devices which have been withdrawn from the market are excluded [30].
e only randomised study comparing HR and THA with published
mid-term outcomes did not demonstrate dierences in revision rates
at a mean of 8 years [15]. An interesting feature of survivorship studies
in which the data is analyzed in more detail is the demonstration
that survivorship of HR implants within certain cohorts of patients
is better than others. In a review of multiple registry data, Corten el
al. showed that HR component sizes greater than 50mm in diameter
had much improved survival rates, and male patients younger than
65yrs had comparable or even slightly improved survivorship with
HR compared with THA [31]. e latest published data analysis from
the UK National Joint Registry shows that in men with a femoral head
size greater than 54mm, revision rates are comparable to the best
performing THAs [32,33]. is analysis is supported by long-term
data from high volume and designer centers using the best performing
implants, demonstrating excellent results in selected cohorts. In young
male patients, 10-year survivorship has been reported in the order of
93-99% [2,34-38]. Many of these studies conrmed that the size of the
implant and the sex of the patient were signicant predictors of failure
during this period and this has been conrmed by further large cohort
analysis [29-40] suggesting that revision rates are higher with smaller
resurfacing implants and female patients.
Adverse events
e incidence of general complications of hip arthroplasty
applicable to both procedures, such as venous thromboembolism,
pulmonary embolism, infection, acetabular component malposition,
nerve palsy or mortality does not dier between HR and THA, and due
restores femoral oset and leg length compared with THA [6,7]. Girard
et al. showed similar ndings in a prospectively randomized study [8].
Notably however, the study by Silva et al. also suggested that if the
pre-operative leg length discrepancy is greater than 1 cm, a THA may
be required in order to restore this variable [7]. A single surgeon trial
by Loughead et al. showed in contrast a more accurate restoration of
oset and leg length in a THA group compared with HR, although the
measured dierences of this study (mean oset changes of 4.5mm and
length increase of 3.1mm), may not be clinically signicant.
Clinical Function
A number of studies have looked at gait and postural balance aer
THA and HR, with conicting results. In a retrospective study, matched
for gender, Mont et al. found better gait parameters and walking speed
in HR patients compared with THA [9]. In an age-matched cohort of
high functioning HR and THA patients with asymptomatic controls,
Shimmin et al could nd no demonstrable dierences, whilst Lavigne
et al. looked at gait speed and postural balance between HR and large-
diameter THA in a prospective, randomized, double-blind trial out to
12 months and again found no signicant dierences between the two
groups [10]. Aqil et al. used a small cohort of 9 patients with one HR
and one THA, showing that the HR side demonstrated gait parameters
which more closely approached those of normal control subjects [11].
From a more subjective point of view, Collins et al. evaluated the
patient’s perception of their articial joint relative to a normal native
joint, and did not nd any signicant dierences between groups of HR
and THA patients [12].
Patient reported outcomes
Perhaps the most important outcome of all is whether hip function
is ultimately improved for the patient. ere is much debate about
how this should be assessed, with many authors commenting on the
potential ceiling eect of common hip function scores masking the
potential benets of one procedure over another [13-15]. A number of
retrospective and non-randomized studies comparing HR and THA
have produced conicting evidence: Some demonstrate higher clinical
scores [16,17] and others no dierence [18-22]. Some of these latter
studies did show higher activity levels for the HR group [18,19,21]
but this was not universal [20,21]. e lack of randomization in all
of these reports does however mean there is a signicant risk of bias.
Two prospective randomized studies by Garbuz et al. and Lavigne et al.
showed similar clinical outcomes and UCLA scores comparing groups
Figure 1: Right total hip arthroplasty and left hip resurfacing.
Citation: Hutt JRB, Lavigne M, Vendittoli PA (2014) Total Hip Arthroplasty versus Hip Resurfacing: Evidence Based Review and Current Indications.
Orthop Muscul Syst 3: 173. doi:10.4172/2161-0533.1000173
Page 3 of 6
Volume 3 • Issue 3 • 1000173
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
trial [62]. Using the size of the last reamer as a surrogate measure of
acetabular bone loss, there were no signicant dierences between
the two groups, although in a small proportion of cases (6.8%) the
acetabular component had to be upsized by 2mm to accommodate the
selected femoral component size. Similarly, Brennan et al. showed no
signicant dierences in dehydrated, defatted acetabular bone reaming
weights between HR and THA [63].
In terms of the functional outcomes of revision, there are multiple
small short-term reports suggesting that the HR revision may have
similar functional outcomes to primary THA (Figure 2a and 2b). Some
of these series report femoral revisions only [64], others a majority of
single component revision [65-67] or a majority of both component
revisions [68]. In contrast, Desloges et al. reported on a retrospective
propensity matched series of HR revisions, and found HR revision
outcomes similar to revision THA, but not to primary THA [69].
e outcome may depend on the reason for revision [70], with poor
outcomes being reported in patients having HR revised for ARMD
[71]. Direct comparison with primary THA is probably not warranted
due to the risk of further surgery. Data from the Australian Registry
suggests that femoral component only HR revision has a similar re-
revision rate to both component revision, but in both cases this is
higher than the revision risk for primary THA [72]. A review of data
from multiple registries had similar ndings, but did point out that
subsequent re-revision rates are similar to that of revision THA [31].
Again, the explosion of manufacturing development in the area of
large metal bearings gives a number of confounding issues here. Until
recently, it was assumed that femoral revision of HR with a well xed
and positioned acetabular component was a relatively straightforward
procedure. However, emerging data from both published series [73],
and the UK registry [74] suggests that large bearing MoM THRs
have unacceptably high failure rates, although data from the Finnish
Registry only found this to be the case in females over 55yrs old [75].
e British Orthopaedic Association now says that surgeons and
hospitals ‘must not use such implants [76]. Although there is little
data regarding the longer term outcome of conversion of a HR to a
stemmed large head MoM THA, it would be reasonable to assume that
the potential consequences are no dierent from using such an implant
in the primary setting. However, each dierent design of LDH THA
performs dierently, and the decision to convert a HR to a LDH THA
should be based on the results of the specic implant to be revised [77].
Conclusions
e explosion of interest in large bearing hip arthroplasty,
both as HR and LDH THA, and the subsequent manufacturing and
commercial rush for involvement has led to the rather unwelcome
to the nature of resurfacing, it is perhaps not surprising that dislocation
rates are lower for this procedure [15,30,41]. Native femoral neck
fracture is unique to HR, and is oen the main cause for revision
[30,32,40]. However, this particular problem may relate to errors in
surgical technique, and this is one of the reasons why the learning curve
for HR is highlighted as an important factor in outcomes [42,43].
One complication that has had signicant attention recently is
adverse reactions to metal debris (ARMD), which is of signicant
interest in both HR and large diameter head THA (LDH THA) with
metal-on-metal bearings. e release of metal ions appears to cause a
spectrum of eects, from asymptomatic raised metal ions with well-
functioning implants to host responses leading to the formation of
pseudotumours, sometimes accompanied by signicant so tissue
and bony destruction [44]. Protocols for accurate diagnosis are still
evolving. Currently, a combination of patient symptoms, metal ion
levels and cross sectional imaging is used to establish the extent of any
problem [44-46]. Identication is important as the consequences, most
notably in the setting of tissue loss, have the potential to be catastrophic
for the patient. e full causation of this problem has not yet been fully
elucidated. ere is undoubtedly a contribution from excessive wear
in poorly engineered implants, and wear problems will be exacerbated
by malposition and smaller components [47,48]. is latter issue has
been cited as one reason for the higher failure rates in female patients,
but there also appears to be a additional and as yet undened patient
specic contribution [49,50] which means the occurrence of this
potentially very serious complication cannot be fully predicted. It is
also possible that a number of dierent pathological processes may
occur in dierent situations, partly explaining the wide spectrum of
noted eects [51]. Despite the concerns and increasing literature on
the subject, however, in a recent review of 2773 HR performed by
11 Canadian centers, only 10 potential ARMD (6 conrmed) were
reported (0.36%) which reects the low occurrence rate of the problem
in a group of dierent HR designs performed by multiple surgeons
[40]. A meta-analysis of the literature identied a pooled incidence of
adverse reactions of just 0.6%, from just fewer than 14,000 MoM THA
or HR operations [52]. ARMD rates do appear to be higher in LDH THA
where altered forces from the large articulation acting at the modular
junction at the stem trunion and head taper have been incriminated
as an additional source of metal ion release [53-55]. Interestingly, and
possibly as a result of the problems with metal bearings, the diagnosis
of ARMD is now increasingly made in the presence of more standard
THA implants without metal articulating surfaces. Again, wear and
corrosion at junction of the femoral trunion and head taper, potentially
as a result of manufacturing changes and more widespread use of larger
diameter heads in all bearing types, has been identied as a potential
causative factor [56-58].
Implant revision
Many of the younger, more active patients at whom HR technology
is targeted will eventually be facing revision surgery. Whilst hip
resurfacing has potential benets for preservation of femoral bone
stock, and thus use of a straightforward THA femoral component
at revision, there are concerns surrounding loss of bone stock aer
removal of a supposedly larger acetabular component. A retrospective
study by Loughead et al. found larger acetabular sizes were used in an
HR group compared with a hybrid THA group [59]. A similar study
by Naal et al came to the same conclusion [60], whereas Moonot et al
suggested that acetabular components in HR were either comparable
to THA or even smaller in women [61]. Vendittoli et al. compared
acetabular bone resection between HR and THA in a randomized
(a) (b)
Figure 2: Hip resurfacing femoral component loosening 1 year after surgery (a)
and revision surgery with a primary cemented stem preserving the acetabular
component (b).
Citation: Hutt JRB, Lavigne M, Vendittoli PA (2014) Total Hip Arthroplasty versus Hip Resurfacing: Evidence Based Review and Current Indications.
Orthop Muscul Syst 3: 173. doi:10.4172/2161-0533.1000173
Page 4 of 6
Volume 3 • Issue 3 • 1000173
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
situation of the orthopaedic community discovering problems and
complications in this area in large patient populations rather than
controlled research cohorts. Undoubtedly, this story still has some way
to play out, and there is a danger that the reports of the benecial sides
to HR technology will be lost as surgeons and implant companies aim
to reclaim the trust of patients. Certainly if HR is to be used, then the
current evidence base would suggest that the patient cohort in which
it should be considered is shrinking. Arguably it should be limited to
young, male patients of sucient dimensions to allow a large bearing
to be implanted. In addition, it ought to be performed by experienced
surgeons in high volume centers. Surgeons wishing to perform the
procedure should recognize the signicant learning curve and seek
appropriate initial training and supervision.
As the current evidence base stands however, despite the
theoretical potential, numerous trials have failed to prove that HR
provides signicant functional benet to patients over THA, although
another way of looking at it would be to say that HR appears to perform
equally well. is may well reect ongoing developments in modularity
and bearing surfaces in THA that allow accuracy of replication of hip
anatomy without the bearing wear issues that initially prompted the
search for an alternative in younger, more active patients. It might also
be argued this is a reection on how we measure our outcomes and
whether we currently have the tools to realistically dierentiate these
gains clinically, but it should also be born in mind that any measurable
dierences should be relevant to the patient and it must be proven that
there are clinically signicant gains to be made before a conclusion of
anything over equivalence is made. As the suitable population for HR
narrows, it may be possible to perform more focused studies to further
establish where such gains might be made.
Again within a young male cohort, however, it appears that one
area in which hip resurfacing is performing as hoped is in its longevity.
Even if functional comparisons are disregarded, this is of signicant
potential benet to a young patient population. In addition, current
data would appear to support the observation that revision of HR to
THA in the absence of infection or ARMD is relatively straightforward
and provides good outcomes. However, the recent concerns over large
head MoM THA probable mean that for the foreseeable future, further
replacement in the presence of a resurfacing is likely to involve a both
component revision. Although this would appear to mitigate some of
the proposed ease of resurfacing revision in the presence of a well xed
acetabular component, it does appear that revision of the acetabular
component should not prove any more destructive than during revision
of a THA, whilst femoral bone stock remains preserved, allowing the
use of a standard primary THA stem.
Overall, although not all the proposed advantages of hip resurfacing
appear to have been realized, the results in a selected patient population
remain encouraging: However, despite the increasing numbers of
higher quality trials, this particular conclusion remains largely based
on level IV evidence. Further studies within more dened cohorts are
required to elucidate the ideal option for young, active patients with
degenerative hip disease.
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Citation: Hutt JRB, Lavigne M, Vendittoli PA (2014) Total Hip Arthroplasty versus Hip Resurfacing: Evidence Based Review and Current Indications.
Orthop Muscul Syst 3: 173. doi:10.4172/2161-0533.1000173
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ISSN: 2161-0533 OMCR, an open access journal
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Citation: Hutt JRB, Lavigne M, Vendittoli PA (2014) Total Hip Arthroplasty versus Hip Resurfacing: Evidence Based Review and Current Indications.
Orthop Muscul Syst 3: 173. doi:10.4172/2161-0533.1000173
Page 6 of 6
Volume 3 • Issue 3 • 1000173
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
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Citation: Hutt JRB, Lavigne M, Vendittoli PA (2014) Total Hip Arthroplasty
versus Hip Resurfacing: Evidence Based Review and Current Indications.
Orthop Muscul Syst 3: 173. doi:10.4172/2161-0533.1000173
