Hip resurfacing is an alternative to total hip arthroplasty (THA; also known as total hip replacement) for individuals with advanced arthritis of the hip. Total hip resurfacing (THR) describes the placement of a shell that covers the femoral head together with implantation of an acetabular cup. Partial hip resurfacing is considered a treatment option for avascular necrosis with collapse of the femoral head.
THR has been investigated in individuals with osteoarthritis, rheumatoid arthritis, and advanced avascular necrosis as an alternative to THA, particularly in young active individuals who would potentially outlive a total hip prosthesis. Therefore, hip resurfacing could be viewed as a time-buying procedure to delay the need for a THA. Proposed advantages of THR compared with THA include preservation of the femoral neck and femoral canal, thus facilitating revision or conversion to a THR, if required. In addition , the resurfaced head is more similar in size to the normal femoral head, thus increasing the stability and decreasing the risk of dislocation compared with THA.
Summary of Evidence
For individuals who have an indication for hip replacement who would outlive a traditional prosthesis and have no contraindication for hip resurfacing who receive a metal-on-metal total hip resurfacing device, the evidence includes randomized controlled trials, numerous large observational studies, large registry studies, and systematic reviews. Relevant outcomes are symptoms, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related morbidity. The efficacy of total hip resurfacing performed with current techniques is similar to that for total hip arthroplasty (THA) over the short-to-medium term, and total hip resurfacing may permit easier conversion to a THA for younger individuals expected to outlive their prosthesis. Based on potential ease of revision of total hip resurfacing compared with THA , current evidence supports conclusions that hip resurfacing presents a reasonable alternative for active individuals who are considered too young for THA when performed by surgeons experienced in the technique. The literature on adverse events (e.g., metallosis, pseudotumor formation, implant failure) is evolving as longer follow-up data become available. Due to the uncertain risk with metal-on-metal implants, the risk-benefit ratio needs to be considered carefully on an individual basis. In addition, emerging evidence has suggested an increased risk of failure in women, possibly due to smaller implant sizes. Therefore, these factors should also be considered in the overall individual evaluation for total hip resurfacing, and individuals should make an informed choice with their treating physicians. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have an indication for hip replacement who would outlive a traditional prosthesis and have no contraindication for hip resurfacing who receive a partial hip resurfacing device, the evidence includes a comparative study. Relevant outcomes are symptoms, change in disease status, functional outcomes, health status measures, quality of life, and treatment-related morbidity. Although evidence has shown better outcomes with total hip resurfacing than with partial hip resurfacing, partial hip resurfacing would be appropriate in younger individuals with osteonecrosis who have contraindications for a metal-on-metal prosthesis. These factors should be considered in the overall individual evaluation for total hip resurfacing, and individuals should make an informed choice with their treating physicians. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
The U.S. Food and Drug Administration lists several contraindications for total hip resurfacing. These contraindications include, but are not limited to, the following:
- Bone stock inadequate to support the device due to:
- severe osteopenia or a family history of severe osteoporosis or severe osteopenia
- osteonecrosis or avascular necrosis with more than 50% involvement of the femoral head
- multiple cysts of the femoral head (greater than one (1) cm)
- Skeletal immaturity
- Vascular insufficiency, muscular atrophy, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery
- Known moderate-to-severe renal insufficiency
- Severely overweight
- Known or suspected metal sensitivity
- Immunosuppressed or receiving high doses of corticosteroids
- Females of child bearing age due to unknown effects on the fetus of metal ion release.
A 2012 Food and Drug Administration advisory panel of experts identified young males with larger femoral heads as the best candidates for hip resurfacing systems. The Food and Drug Administration has advised that a metal-on-metal hip implant should be selected only after determining that the benefit-risk profile of using a metal-on-metal hip implant outweighs that of using an alternative hip system. Factors to consider include the individual's age, sex, weight, diagnosis, and activity level. Individuals should be informed about the benefits and risks of metal-on-metal hip implants, including the risk that the hip implant may need to be replaced. Individual expectations and the potential complications of surgery with a metal-on-metal hip implant should be discussed.
Total hip resurfacing should be performed by surgeons adequately trained and experienced in the specific techniques and devices used.
Metal-on-metal total hip resurfacing with a device system approved by the US Food and Drug Administration may be consideredmedically necessaryas an alternative to total hip replacement when the individual:
- Is a candidate for total hip replacement; AND
- Is likely to outlive a traditional prosthesis; AND
- Does not have a contraindication for total hip resurfacing (see Policy Guidelines section)
Partial hip resurfacing with a Food and Drug Administration-approved device may be considered medically necessary in individuals with osteonecrosis of the femoral head who have one or more contraindications for metal-on-metal implants and meet the following criteria:
- The individual is a candidate for total hip replacement; AND
- Is likely to outlive a traditional prosthesis; AND
- The individual has known or suspected metal sensitivity or concern about potential effects of metal ions; AND
- There is no more than 50% involvement of the femoral head; AND
- There is minimal change in acetabular cartilage or articular cartilage space identified on radiography
All other types and applications of hip resurfacing are considered investigational