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.
Metal-on-metal total hip resurfacing with a device system approved by the US Food and Drug Administration may be considered medically necessary as an alternative to total hip replacement when the individual:
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:
All other types and applications of hip resurfacing are considered investigational.
The Hip Society (2012) published an algorithmic approach to the diagnosis and management of metal-on-metal (MoM) arthroplasty (total hip arthroplasty [THA], total hip resurfacing [THR]. The review indicated that adverse local tissue reactions to metal debris are escalating and that all arthroplasty individuals returning for follow-up should be queried for pain, discomfort, or compromise of function. Symptomatic individuals should be evaluated for all intra-articular and extra-articular causes of pain, including aseptic loosening, sepsis, component malposition, or fluid collections and/or masses about the hip. The Hip Society stated that there is still a role for MoM resurfacing arthroplasty in select individuals groups. The ideal candidate is a man younger than age 55 with osteoarthritis and a femoral head size larger than 50 mm. Another relative indication is the need or desire to return to a very high activity level at work or in recreation. Contraindications to MoM resurfacing include known or suspected metal sensitivity; moderate or worse renal function; women who may become pregnant; osteoporosis; large cysts; and avascular necrosis more than 50%.
California Technology Assessment Forum
The California Technology Assessment Forum (2011) concluded there was no evidence that the potential benefits of hip resurfacing outweighed the potential risks. Revision rates appeared to be higher in individuals receiving THR procedures than in those receiving THA, which is of particular importance because the THR procedure targets young people. This risk may be particularly high in women. In addition, the elevated levels of metal ions were concerning. Although the clinical significance of these elevated ion levels is still uncertain, they are implicated in the development of aseptic lymphocytic vasculitis-associated lesions, often seen in aseptic failure of THR. Pseudotumors appear to be a more severe manifestation of aseptic lymphocytic vasculitis-associated lesions. It was recommended that MoM hip resurfacing using the Birmingham Hip Resurfacing, Cormet 2000, or Conserve Plus devices did not meet California Technology Assessment Forum criteria for safety, efficacy, or improvement in health outcomes for individuals as an alternative to THA.
American Academy of Orthopaedic Surgeons
The American Academy of Orthopaedic Surgeons published a technology overview on MoM hip resurfacing. To compare revision rates between MoM hip resurfacing and THA, the Academy analyzed three joint registries, which indicated that individuals who received THR were at greater risk for revision than individuals who received THA. One registry suggested that younger men may have a lower revision rate after THR than THA, although the available data were not found to clearly establish an advantage for this subgroup. There was no conclusive evidence on predictors of successful or unsuccessful outcomes.
The Academy (2011) provided a technology overview of modern MoM hip implants (both THA and THR). This document did not recommend for or against use of MoM hip implants.
National Institute for Health and Care Excellence
The NICE (2014) updated its guidance on THA and THR for end-stage arthritis of the hip.The NICE concluded that both THA and THR were options for treating end-stage arthritis of the hip, although clinicians may be more likely to offer resurfacing arthroplasty to men than to women because of higher revision rates observed in women. The NICE concluded that THA was more effective and less costly than THR in all analyses, that the revision rate was the most important key driver of costs and quality-adjusted life years, and that because the predicted revision rate of THA was less than 5% at ten years in the population for whom both THA and THR were suitable, the revision rate standard for THR should be the same as that for THA. The NICE recommended specific prostheses for THA and THR only if the prostheses have revision rates of 5% or less at ten years