Hip Resurfacing is the Ideal First Choice in the Athlete with Arthritis? Get Real: We Know the Answer, it’s a Modern Total Hip Replacement Matthew Hepinstall, MD Center for Joint Preservation & Reconstruction
Disclosures: Paid Consulting: Corin, Stryker Institutional Research Support: Acelity, Stryker Royalties: Corin Speaking: Stryker, Smith & Nephew Center for Joint Preservation & Reconstruction
Disclosures: I did a lot of resurfacings in training. They generally did well. There was no epidemic of problems. I enjoy the resurfacing operation. The few I have done in practice have done well. Based on published data, I cannot bring myself to sell a patient on resurfacing. Center for Joint Preservation & Reconstruction
Center for Joint Preservation & Reconstruction
AUSTRALIAN JOINT REGISTRY RESULTS OF METAL-ON-METAL HIP RESURFACING 1 1 Prosser GH, et al. Acta Orthopaedica 2010:81;66-71. Center for Joint Preservation & Reconstruction
Center for Joint Preservation & Reconstruction
Hip Resurfacing is the Ideal First Choice in the Athlete with Arthritis? Get Real: We Know the Answer, it’s a Modern Total Hip Replacement Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Better recovery with fewer complications 2 Few dislocations despite no hip precautions Improved function 3 Proprioception from femoral neck Eliminate thigh pain from femoral stem More anatomic head size, leg length and offset Better durability 4 Diminished wear with metal-on-metal Easier revision 5 Femoral bone preservation 2 Brooks PJ, Bone Joint J 2016 3 Szymanski C, Orthop Traumatol Surg Res 2012 4 Amstutz HC, et al. Orthop Clin North Am 2011 5 Gerhardt DM, et al. Hip Int 2017 Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Better recovery with fewer complications No hip precautions and few dislocations 6 Large diameter head 7 Are hip precautions required in modern THA? 8 Anterior, lateral & superior approaches Modern posterior soft tissue repairs 6 Morse KW, et al. Hip Int 2017 7 Cadossi M, et al. Orthopedics 2015 8 Kornuijt A, et al. Bone Joint J 2016 Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Better recovery with fewer complications No hip precautions and few dislocations 6 Large diameter head 7 THA dislocation exceedingly rare in active young male candidates for resurfacing 9 9 Barnsley L, et al. Geriatr Orthop Surg Rehabil 2015 Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Better recovery with fewer complications No hip precautions and few hip dislocations 6 Large diameter head 7 THA requires less extreme exposure! 10, 11 10 Brun Ol, et al. Hip Int 2017 11 von Rottkay E, et al. Int Orthop 2017 Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Better recovery with fewer complications No hip precautions and few dislocations 6 Large diameter head 7 Hard to have a better recovery if you develop femoral neck fracture after resurfacing 12 12 Gross TP, et al. J Arthoplasty 2014 Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Improved function Proprioception from femoral neck REFUTED when normalized against non-operative limb 13 Higher activity level CONTESTED (selection bias, comparisons to 28 mm heads, differing instructions) 14-16 Eliminate thigh pain from femoral stem with more physiologic stress CONTESTED 15 More anatomic head size, leg length and offset SUPPORTED 17 Hard to alter pathologic anatomy (FAI, LLD) 13 Larkin B et al. CORR 2014 14 Garbus DS CORR 2010 15 Lavigne M CORR 2010 16 Penny JO Acta Orthopaedica 2013 17 Brown NM, et al. Orthopedics 2013 Center for Joint Preservation & Reconstruction
HARDER TO ALTER ABNORMAL ANATOMY Courtesy of Jose Rodriguez Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Better durability 18 Diminished volumetric wear w/ metal-on-metal Fluid-film lubrication (vs boundary vs mixed) Wear is very dependent on implant position 19,20 Contact Patch to Rim (CPR) distance Correlates with metal ion levels 18Amstutz HC, et al. HSS J 2012 19Amstutz HC, et al. Bone & Joint J 2017 19 Amstutz HC, et al. The Bone & Joint Journal 2017. Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Better durability 18 Diminished volumetric wear w/ metal-on-metal Fluid-film lubrication (vs boundary vs mixed) Biologic response to metal is different 19,20 PSEUDOTUMOR! Volumetric comparisons not meaningful 18Amstutz HC, et al. HSS J 2012 20Gustafson K, et al. Acta Orthop 2014 21Berber R, et al. Acta Orthop 2015 22Wong JML, et al. Clin Orthop Relat Res 2015 Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Better durability 18 Diminished volumetric wear with metal-on-metal Fluid-film lubrication (vs boundary vs mixed) Actual registry revision rates tell a different story 1,21 1 Prosser GH, et al. Acta Orthopaedica 2010 22 Wong JML, et al. Clin Orthop Relat Res 2015 Center for Joint Preservation & Reconstruction
PROPOSED ADVANTAGES OF HIP RESURFACING Easier revision Femoral bone preservation 22 If pseudotumor, definitely not! 23 Poor Survivorship and Frequent Complications at a Median of 10 Years After Metal-on-Metal Hip Resurfacing Revision 23 23 Su EP, et al. HSS J 2012 24 Mathary GS, et al. CORR 2017 Center for Joint Preservation & Reconstruction
HIP RESURFACING IS HARD Learning curve 24 Narrow indications Exposure Cup and femoral position 25 Nunley RM, et al. Clin Orthop Relat Res 2010. Center for Joint Preservation & Reconstruction
HIP RESURFACING IS UNFORGIVING 19 Femoral implant positioning Notching and fracture Recurrent impingement Cup position Contact Patch to Rim (CPR) distance correlates with metal ion levels 19 Amstutz HC, et al. The Bone & Joint Journal 2017. Center for Joint Preservation & Reconstruction
HIP RESURFACING INDICATIONS ARE NARROW 1 Center for Joint Preservation & Reconstruction
HIP REPLACEMENT IS A MATURE, PROVEN, RELIABLE AND FORGIVING APPROACH FOR THE HIGH DEMAND PATIENT Good durability despite less than optimal precision 26, 27 26 Callanan et al. CORR 2011 27 Stea, et al. JBJS 2014 Center for Joint Preservation & Reconstruction
HIP RESURFACING IS NOT Device recalls Durom ASR Devices no longer distributed in USA Cormet Outcomes device and technique specific BHR Learning curve Narrow indications Technically challenging / unforgiving Center for Joint Preservation & Reconstruction
HIP REPLACEMENT vs. HIP RESURFACING PROVEN SAFETY AND EFFICACY vs. APPEALING CONCEPT WITH MIXED RESULTS • Optimal role for resurfacing (if any) is yet to be elucidated. Center for Joint Preservation & Reconstruction
References 1. Prosser GH, et al. Acta Orthopaedica 2010:81;66-71 21. Berber R, et al. Acta Orthop 2015 2. Brooks PJ, Bone Joint J 2016 22. Wong JML, et al. Clin Orthop Relat Res 2015 3. Szymanski C, Orthop Traumatol Surg Res 2012 23. Su EP, et al. HSS J 2012 4. Amstutz HC, et al. Orthop Clin North Am 2011 24. Mathary GS, et al. CORR 2017 5. Gerhardt DM, et al. Hip Int 2017 25. Nunley RM, et al. Clin Orthop Relat Res 2010 6. Morse KW, et al. Hip Int 2017 26. Callanan et al. CORR 2011 7. Cadossi M, et al. Orthopedics 2015 27. Stea, et al. JBJS 214 8. Kornuijt A, et al. Bone Joint J 2016 9. Barnsley L, et al. Geriatr Orthop Surg Rehabil 2015 10. Brun Ol, et al. Hip Int 2017 11. von Rottkay E, et al. Int Orthop 2017 12. Gross TP, et al. J Arthoplasty 2014 13. Larkin B et al. CORR 2014 14. Garbus DS CORR 2010 15. Lavigne M CORR 2010 16. Penny JO Acta Orthopaedica 2013 17. Brown NM, et al. Orthopedics 2013 18. Amstutz HC, et al. HSS J 2012 19. Amstutz HC, et al. The Bone & Joint Journal 2017 20. Gustafson K, et al. Acta Orthop 2014 Center for Joint Preservation & Reconstruction
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