This week’s Orthopaedic Crossfire® debate was part of the Annual Current Concepts in Joint Replacement® (CCJR), Winter meeting, which took place in Orlando. This week’s topic is “Why Cut Off Your Head? Resurface It Instead.” For is Peter J. Brooks, M.D., F.R.C.S.(C), Cleveland Clinic, Cleveland, Ohio. Opposing is Steven J. MacDonald, M.D., F.R.C.S.(C), University of Western Ontario, London, Ontario, Canada. Moderating is Clive P. Duncan, M.D., F.R.C.S.(C), University of British Columbia, Vancouver, British Columbia, Canada.
Dr. Brooks: I’m primarily going to be mentioning the BHR—the Birmingham Hip Resurfacing system—but this applies to some other designs as well.
The difference between resurfacing and total hip replacement is the difference between putting on a hat and cutting off your head. But it’s not a procedure you should think of as competing with total hip replacement. Keep that in mind.
Resurfacing complements total hip replacement in a small subset of patients now—the young, active male with osteoarthritis. Also keep in mind that metal-on-metal total hip replacement is a very different problem. Most of those were associated with trunnionosis problems because of the large head exerting excessive torque on the small Morse taper.
And Clive, your group published on that some years ago.
Steve is going to show you data which compares hip replacement to resurfacing in a global sense. And yes, there is a 37% higher failure rate in the latest Australian joint registry, if you do resurfacing. But that misses the point. The registry data is at a 30,000-foot overview of all patients, of all ages, genders, sizes and diagnosis with multiple brands of resurfacing devices, some of which are failing at 30%, and have been recalled, and surgeons in all levels of experience and volume at different centers around Australia.
But we’ve learned, and it’s been a long time coming, that there is a small best cohort for resurfacing, which are the young, active males with osteoarthritis. Additionally, it’s important to use an implant with a good track record and preferably do the surgery in a high-volume center because these are difficult procedures.
So, let’s say you look at the very same registry data and you granularize it down. You have only two resurfacing devices being done in Australia now—the BHR and the Adept, which are very similar in many ways, including metallurgy. And they have a one-third lower failure rate in males under 55 at 10 years, than do the total hips, and that’s excluding metal-on-metal total hips, which is appropriate since they’re not done any more.
So now it’s a lower failure rate in this small, select group of young men. And if you’re a young man under 55—and I see these people—they don’t care that it’s equal or better. They’d be happy if it was almost as good because they know that it saves a lot of their bone. It allows them to return to their full activity and that includes sports and even professional competitive sports. Better revision options in most cases in the future. And they’re young.
Resurfacing certainly saves a lot of bone on the day of surgery and it goes on saving bone in the upper femur because there’s no stress shielding. The loading biomechanically is much more normal. Dislocations and leg length problems are quite rare. And remember that these two problems are some of the most common complaints of total hip replacement.
In 2013 independent researchers from Oxford and Southampton (Carr et al., BMJ) looked up the data from the UK hospital episode statistics database. Almost 400,000 total hip replacements compared with 18,000 resurfacings reached the conclusion—reduced long-term mortality with hip resurfacing—compared to patients receiving other types of hip replacement.
Similar findings in the Australian Registry—not as well analyzed with the multi-variate, just age and gender—but showing at 15 years a higher mortality in the total hip group. And by the way, we’re finding the same thing in our series at the Cleveland Clinic—lower mortality when compared with total hip replacement. Those were age-matched patients under 55.
