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. 2012 Oct 26;36(12):2399–2410. doi: 10.1007/s00264-012-1686-3

Hip resurfacing: a systematic review of literature

Régis Pailhé 1,3,✉, Akash Sharma 1, Nicolas Reina 2, Etienne Cavaignac 2, Philippe Chiron 2, Jean-Michel Laffosse 2
PMCID: PMC3508060  PMID: 23100124

Abstract

Purpose

We conducted a systematic review of the literature in order to take stock of hip resurfacing according to the principle of “evidence based medicine”. Our main objective was to compare the rate of revision of resurfacing implants with survival limits set by the National Institute of Clinical Excellence (NICE).

Methods

A systematic review was undertaken of all published (Medline, Cochrane, EMBASE) literature research databases up to July 2012 as recommended by the PRISMA statement. Data extraction focused on functional outcomes, complications and survival rates. The survival rates of implants were analysed according to the mean of the series in comparison to the NICE criteria.

Results

Fifty-three studies were identified and included 26,456 cases with an average of 499.17 ± 856.7 (range, 38–5000) cases per study. The median survival was 95.57 % ± 3.7 % (range, 84–100). The percentage of studies which satisfied the criteria set by NICE was 69.8 %. In terms of cumulative revision rates pondered by the number of implants, BHR®, Conserve Plus® and Cormet® showed the best results. The mean postoperative score was 91.2 ± 7.72 (range, 68.3–98.6). There was no statistically significant difference between implants in terms of functional outcomes.

Conclusion

On the basis of the current evidence base, this review of the literature emphasises the importance of certain parameters that can improve the results of resurfacing. The type of implant seems to play an important role as does patient selection.

Introduction

After a period of popularity, hip resurfacing has seen a number of indications to be decreasing [1]. It is currently the subject of numerous concerns with regards to the presence of metal ions in the blood, even if there is no conclusive evidence of a carcinogenic effect [2]. Furthermore, many publications seem to show excellent results. We conducted a systematic review of the literature in order to take stock of this surgical technique according to the principle of “evidence based medicine.”

Our main objective was to compare the rate of revision of resurfacing implants with survival limits set by the National Institute of Clinical Excellence (NICE) (maximum of 10 % at ten years), being part of the National Health System (NHS) in England and Wales [3–5]. The secondary objectives were to evaluate the functional outcome and complications associated with hip resurfacing as well as differences between these implants.

Materials and methods

The research was conducted on July 14, 2012 using the Cochrane databases, EMBASE and MEDLINE as recommended by The PRISMA statement [6]. The electronic search included articles published until 25 July 2012. The following terms used the joints “AND”, “NOT” and “OR”: hips, femur head, femoral head, femur neck, femoral neck, resurfac* outcome, follow-up, FU, prosthesis failure, pseudotumor, pseudotumour, mechanical stress, gait, patient satisfaction, activity, activities, surviv* and risk factors. All titles and abstracts were reviewed by a single observer, and for studies meeting eligibility criteria the full article was obtained. The reference lists of meta-analysis and systematic reviews of the literature were examined to avoid missing studies not identified by the search. The inclusion criteria were: publication in English and studies reporting survival or revision of the implant with a minimum of at least six-months follow up. Exclusion criteria were: studies on hemi-arthroplasty, studies reporting results after revision of a resurfacing, retrospective studies on implant failures, technical note type studies, studies reporting only laboratory results, histological studies, in-vitro simulation study, bioengineering studies, radiological studies, studies of national registries, and clinical case studies of peri-prosthetic bone density. If articles described the same series of patients, we included the most recently published series with the largest number of patient population. The criteria for inclusion/exclusion was controlled by two different observers with the inclusion of a third in case of disagreement. Data extraction focused on the type of prosthesis, the design of the study, the baseline characteristics of patients, the mean follow-up, functional scores, survival rates, and the type and number of complications. Functional scores were standardised as far as possible on a scale of 0 to 100, with 100 representing the best possible functional outcome. The survival rate of implants was analysed according with respect to the mean of the series and compared with the NICE criteria. Quality of studies, in terms of level of evidence, was judged using the GRADE evaluation system (Grading of Recommendations Assessment, Development and Evaluations) classifying the quality of education in high, moderate, low and very low [7].

Results

Research has revealed 780 citations published between 1 January 2005 and 14 July 2012. The number of studies identified according to the criteria for inclusion/exclusion was 53 (Fig. 1).

Fig. 1.

Fig. 1

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Flow chart of the PRISMA procedure of systematic review of the literature

Six studies examined the ASR Hip Resurfacing® implant (DePuy Orthopaedics Inc., Warsaw, Indiana), 22 the BHR implant® (Smith & Nephew Inc., Memphis, Tennessee), 11 the Conserve Plus® implant (Wright Medical Technology Inc, Arlington, Tennessee), five reviewed the Cormet 2000® implant (Corin Group PLC, Cirencester, United Kingdom) and four examined the Durom® implant (Zimmer, Warsaw, Indiana). One study reported the results of both BHR® and ASR® implants. Another study described the use of both the McMinn implant® (Corin Group PLC) and BHR® implant and another described only the second generation McMinn implant® (McMinn hybrid resurfacing; Corin Group PLC) which was only in use around 1996. One study compared the BHR® implant to the Recap® implant (Biomet Inc., Warsaw, Indiana). The data presented only six of the 11 resurfacing devices currently on the market. We were not able to identify studies that met our inclusion/exclusion for ACCIS® implants (Implantcast GmbH, Buxtehude, Germany), Adept® (Finsbury Orthopaedics), EskaBionik® (Eska Implants, Lübeck, Germany), Icon® (International Orthopaedics, Geisingen, Germany), and Mitch® (Stryker, Kalamazoo, Michigan).

Three randomised clinical trials and eight comparative studies compared the results of resurfacing implants to conventional total hip arthroplasty. The average survival rate for resurfacing implants was 94.84 % ± 4.7 (range, 89.1–100) and functional scores were significantly better for them in all studies. The mean duration of follow-up for the majority of these studies was five years. The study by Baker et al. [8] reported a mean follow-up of nine years (range, 8.2–10.3) for the resurfacing group (BHR®) and 10.7 years (range, 7.5– 14.5 ) for the total hip arthroplasty group (THA). A randomised clinical trial had a mean follow-up of 4.7 years for both groups (Durom®).

Only two series directly compared the results of two different resurfacing implants. One study compared the results of 29 patients who underwent bilateral resurfacings, with a BHR® implant on one side and a ReCap® implant on the contralateral side. This study did not show any revision of either implants at a mean follow up of 4.8 years for the BHR® implant and 1.4 years for the ReCap® implant. Another study analysed a prospective series of 660 procedures with BHR® implants, ASR® and ASR® THA implants. This study found that 17 patients needed a revision (ASR® implant in all cases). The revision rate was 0 % for the BHR® implant, 3.2 % for ASR® and 6 % for THA® ASR. Steiger et al. [9] found similar results. The cumulative revision rate at five years was 10.9 % (95 % CI, 8.7–13.6) with the ASR implant and 4 % (95 % CI, 3.7–4.5) for other resurfacing implants. The cumulative revision rate due to metallosis was 1.7 % (95 % CI, 0.9–3.1) with the ASR® implant against 0.3 % (95 % CI, 0.2–0.5) for other implants.

Thirty-seven studies reported single arm results in terms of survival/revision for the different resurfacing implants (Table 1).

Table 1.

Study results

Authors Study design Implant Number of hips Percent (%) males Mean age % OA primary/ OA secondary/Other Mean follow-up (years) Percent (%) lost to follow-up Number of revisions Survival rate % (95 % CI)
Amstutz et al. [10] Series of cases Conserve plus 1107 74 50 NS 6.8 0.2 44 96
Aulakh et al. [11] Series of cases BHR 202 75 42 50/0/50 7.5 0 6 97.7 AVN; 95 OA
Baker et al. [8] Comparative study BHR vs THA BHR 54 BHR vs 54 THA 74 50 100/0/0 9 NR 5 BHR vs 9 THA NR
Beaulé et al. [12] Series of cases Conserve plus 116 81 47 81/9/10 3.2 1.9 2 98.1
Bergeron et al. [13] Series of cases ASR 228 80 54 97/0/3 4.6 3 8 94.8
Bose et al. [14] Series of cases BHR 96 84 39 0/100/0 5.4 0 3 95.4
Carrothers et al. [15] Multicentric study BHR 5000 67 53 NS 7.1 NR 182 96.3
Costa et al. [16] Comparative study Cormet vs THA Cormet 73 Cormet vs 137 THA 86 (cormet) vs 47(THA) 53 NS 2.4 NR 0 Cormet vs 3 THA NR
Daniel et al. [17] Series of cases McMinn et BHR 446 79 48 100/0/0 3.3 0 1 99.8
Daniel et al. [18] Series of cases McMinn 2nde generation 184 59 54 82/0/18 10.5 0.5 30 84
De Smet et al. [19] Series of cases BHR 252 69 50 81/6/13 5 1.5 3 98.9
De Steiger et al. [9] Comparative study ASR vs THA ASR 1167 ASR 95 53 NR 5 NR 89.1
Della Valle et al. [20] Series of cases BHR 537 71 52 89/6/5 0.87 NR 14 NR
Delport et al. [21] Comparative study BHR vs Recap BHR et Recap 56 82 52 NS 4.8 NR 0 NR
Fowble et al. [22] Comparative study Conserve plus vs THA Conserve plus 50 Conserve plus vs 44 THA 62 50 98/1/1 3.2 NR 1 Conserve plus vs 0 THA NR
Giannini et al. [23] Series of cases BHR 350 52 51 52/22/26 2 NS 4 98.8
Gravius et al. [24] Series of cases Durom 82 56 53 93/7/0 2.4 2.4 2 97.6
Gross et al. [25] Series of cases Cormet 100 8 NR 21 93
Heilpern et al. [26] Series of cases BHR 113 58 54 88/4/8 5 3 4 96.3 (92.8–99.8)
Hing et al. [27] Series of cases BHR 230 66 52 NS 5 0.5 2 97.8 (97.1–100)
Hulst et al. [28] Series of cases Conserve plus 643 67 49 65/15/20 10.4 NR 45 98.3
Jameson et al. [29] Series of cases ASR 214 60 56 68/5/27 3.6 0 12 93 (80–98)
Khan et al. [30] Series of cases BHR 679 60 51 NS 6 2 29 95.7 (94.4–97.4)
Killampalli et al. [31] Series of cases Cormet 100 61 56 97/1/2 5 0 0 100
Kim et al. [32] Series of cases Conserve plus 200 78 49 86/4/10 2.6 0 14 93
Klein et al. [33] Series of cases ASR 115 47 58 100/0/0 1 0 13 88.7
Langton et al. [34] Comparative study BHR vs ASR BHR et ASR 155 BHR vs 505 ASR 54 56 NS 2.9 NR 17 ASR vs 0 BHR NR
Larbpaiboonpong et al. [35] Series of cases BHR 40 58 41.3 35/52/13 1.4 0 1 97.5
Lei et al. [36] Series of cases Durom 90 52 47 50/0/50 2.3 0 1 98.9
Mackenzie et al. [37] Comparative study BHR vs THA BHR 499 75.5 49.1 100/0/0 2 0 0 100
Madadi et al. [38] Comparative study ON vs OA Cormet 52 52 35 50/0/50 3.4 NR 6 88.4
Madhu et al. [39] Series of cases BHR 117 58 54 56/44/0 7 1 8 91.5 (85.4–97.6)
Malhotra et al. [40] Series of cases ASR 32 70 33 0/0/100 3.6 0 1 96.8
Marker et al. [41] Series of cases Conserve plus 361 71 50 74/15/11 4.9 NR 23 93.6
Marulanda et al. [42] Series of cases BHR 230 73 55 87/0/13 1.3 NS 3 98.7
McAndrew et al. [43] Series of cases BHR 180 NS 56 94/0/6 2 0 3 98.3
McBryde [44] Series of cases BHR 2123 62 55 100/0/0 3.46 0 48 97.5 (96.3–98.3)
McMinn et al. [45] Series of cases BHR 3095 NS 53 8 0 68 98
Mont et al. [46] Comparative study Conserve plus vs THA Conserve plus 54 Conserve plus vs 54 THA 75 52 100/0/0 3.5 0 2 Conserve plus vs 2 THA NR
Mont et al. [47] Series of cases Conserve plus 1016 28 50 77/11/12 2.8 6.3 54 94.2 (90–96.7)
Naal et al. [48] Series of cases Durom 100 66 52 79/6/15 5 NR 11 88.2
Ollivere et al. [49] Series of cases BHR 463 66 56 NS 5 0.6 13 95.8 (94.1–96.8)
Sandiford et al. [50] Comparative study BHR vs THA BHR 141 BHR vs 141 THA 66 54 100/0/0 1.6 NS 0 NS
Siebel et al. [51] Series of cases ASR 300 64 57 NS 0.6 0 8 97.2
Smolders et al. [52] Clinical randomised trial Conserve plus 38 conserve plus vs 33 THA 55 58 90/0/10 1.7 NS 1 Conserve plus vs 2 THA NS
Steffen et al. [53] Series of cases BHR 610 59 52 85/9/6 7 0.33 23 95 (95.3–99.2)
Stulberg et al. [54] Series of cases Cormet 337 68 50 86/0/14 2 8.3 24 92.9
Swank and Alkire [55] Comparative study BHR vs THA BHR 128 BHR vs 106 THA 62 51 71/5/24 1 0 2 BHR vs 0 THA 98.1
Takamura et al. [56] Comparative study Conserve plus 500 63 48 63/18/19 8 NR 34 without FNN vs 7 with FNN 86.7 with FNN vs93.6 without FNN
Treacy et al. [57] Series of cases BHR 144 55 100/0/0 3.5 10 48 97.5 (96.3–98.3)
Vendittoli et al. [58] Randomised controlled trial Durom 109 Durom vs 100 THA 63 49 31/9/60 4.7 0 4 vs 2 96.3
Wang et al. [59] Randomised controlled trial Conserve plus 37 Conserve vs 39 THA 14 45.7 0/0/100 4.9 0 0 100
Witzleb et al. [60] Series of cases BHR 300 57 49 19/63/18 2 0.7 6 98
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Of all the studies, the total number of resurfacing performed was 26,456 and the average number of cases per study was 499.17 ± 856.7 (range, 38–5000). The mean follow up was 4.3 ± 2.54 (range, 0.6–10.5) years. The average age of patients was 50.75 years ±5.19 (range, 35–58). The percentage of males per study was 64.73 % ± 13.55 (range, 28–95). The median survival was 95.57 % ±3.7 (range, 84–100). The percentage of studies which satisfied the criteria set by NICE was 69.8 %. In terms of cumulative revision rates pondered by the number of implants BHR®, Conserve Plus®, Cormet® showed the best results (Figs. 2, 3, 4, and 5).

Fig. 2.

Fig. 2

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Survival rate for the BHR implant

Fig. 3.

Fig. 3

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Survival rate for implant Conserve Plus

Fig. 4.

Fig. 4

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Survival rate for implant Cormet

Fig. 5.

Fig. 5

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Survival rate for the ASR implant

The details of the functional results for each study are reported in Table 2. The mean postoperative score was 91.2 ± 7.72 (range, 68.3–98.6). There was no statistically significant difference between implants in terms of functional outcomes.

Table 2.

Functional results 

Authors Implant Number of hips Functional score Preoperative Postoperative
Amstutz et al. [10] Conserve plus 1107 UCLA 48 86.5
Aulakh et al. [11] BHR 202 HHS 62 ON vs 58 OA 96 ON vs 95.8 OA
Baker et al. [8] BHR 108 OXFORD
Beaulé et al. [12] Conserve plus 116 HHS 53.1 90.1
Bergeron et al. [13] ASR 228 HHS 46.6 91
Bose et al. [14] BHR 96 UCLA NR 68.6
Carrothers et al. [15] BHR 5000 HHS NR 96
Costa et al. [16] Cormet 73 NR NR NR
Daniel et al. [17] McMinn and BHR 446 OXFORD NR 77.5
Daniel et al. [18] McMinn 2nd generation 184 OXFORD NR 68.3
De Smet et al. [19] BHR 252 HHS NR 97.2
De Steiger et al. [9] ASR 1167 NR NR NR
Della Valle et al. [20] BHR 537 NR NR NR
Delport et al. [21] BHR and Recap 56 HHS 45 96.3
Fowble et al. [22] Conserve plus 50 HHS 45 97
Giannini et al. [23] BHR 350 HHS 57 98.6
Gravius et al. [24] Durom 82 HHS 40.1 94.6
Gross et al. [25] Cormet 373 HHS 57 96
Heilpern et al. [26] BHR 113 HHS NR 96.4
Hing et al. [27] BHR 230 HHS 62.2 95.2
Hulst et al. [28] Conserve plus 643 NR NR NR
Jameson et al. [29] ASR 214 HHS 51.3 94.5
Khan et al. [30] BHR 679 HHS 47 95
Killampalli et al. [31] Cormet 100 OXFORD 37.5 89.6
Kim et al. [32] Conserve plus 200 HHS 55.8 92.1
Klein et al. [33] ASR 115 HHS 59 96
Langton et al. [34] BHR and ASR 660 HHS NR 94 ASR vs 97 BHR vs 76 ASR THA
Larbpaiboonpong et al. [35] BHR 40 HHS 35.1 96.4
Lei et al. [36] Durom 90 HHS 57 93
Mackenzie et al. [37] BHR 499 WOMAC 49.9 BHR vs 42.3 THA 91.9 BHR vs 87.1 THA
Madadi et al. [38] Cormet 52 HHS NR 96
Madhu et al. [39] BHR 117 HHS NR 84.4
Malhotra et al. [40] ASR 32 HHS 39.6 88.4
Marker et al. [41] Conserve plus 361 NR NR NR
Marulanda et al. [42] BHR 230 OXFORD 27 78
McAndrew et al. [43] BHR 180 HHS 44 72
McBryde [44] BHR 2123 NR NR NR
McMinn et al. [45] BHR 3095 OXFORD NR 97.9 (13)
Mont et al. [46] Conserve plus 54 HHS 52 90
Mont et al. [47] Conserve plus 1016 HHS NR 93.1
Naal et al. [48] Durom 100 HHS NR 94.7
Ollivere et al. [49] BHR 463 HHS NR NR
Sandiford et al. [50] BHR 141 HHS 54.1 HR vs 46.4 THA 96.8 HR vs 95.8 THA
Siebel et al. [51] ASR 300 HHS 44 89
Smolders et al. [52] Conserve plus 38 UCLA NR 80 HR vs 70 THA
Steffen et al. [53] BHR 610 HHS NR 93.1
Stulberg et al. [54] Cormet 337 HHS 50.1 96.7
Swank and Alkire [55] BHR 128 HHS 49 96
Takamura et al. [56] Conserve plus 500 UCLA
Treacy et al. [57] BHR 2123 OXFORD 34.5 95.8
Vendittoli et al. [58] Durom 109 WOMAC 45.1 90.6
Wang et al. [59] Conserve plus 37 HHS 35.4 HR vs 35.9 THA 94.5 HR vs 95.1 THA
Witzleb et al. [60] BHR 300 HHS 51 96
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UCLA UCLA activity score, HHS Harris hip score, OXFORD Oxford hip score, NR not reported, WOMAC Western Ontario McMaster osteo-arthritis index

The revision rate was 4.4 % if we considered all cases in these published series. The most frequent complications (Table 3; Fig. 6) were aseptic loosening 33.5 %, followed by femoral fractures.

Table 3.

Complications

Authors Implant Number of hips Number of revisions Neck fracture Aseptic loosening Infection ALVAL Dislocation Malpositions Persistent pain Avascular necrosis Other
Amstutz et al. [10] Conserve plus 1107 44 9 26 2 0 1 0 0 0 6
Aulakh et al. [11] BHR 202 6 3 1 1 0 0 0 0 1 0
Baker et al. [8] BHR 108 5 0 0 0 0 0 0 0 5 0
Beaulé et al. [12] Conserve plus 116 2 0 2 0 0 0 0 0 0 0
Bergeron et al. [13] ASR 228 8 8 1 1 5 0 0 0 1 0
Bose et al. [14] BHR 96 3 0 1 0 0 0 0 0 2 0
Carrothers et al. [15] BHR 5000 182 54 56 17 15 5 3 0 30 2
Costa et al. [16] Cormet 73 0 0 0 0 0 0 0 0 0 0
Daniel et al. [17] McMinn and BHR 446 1 0 0 0 0 0 0 0 1 0
Daniel et al. [18] McMinn 2nd generation 184 30 0 29 1 0 0 0 0 0 0
De Smet et al. [19] BHR 252 3 1 0 1 0 0 0 0 1 0
De Steiger et al. [9] ASR 1167 210 19 92 42 26 15 0 0 0 16
Della Valle et al. [20] BHR 537 14 10 2 0 0 2 0 0 0 0
Delport et al. [21] BHR and Recap 56 0 0 0 0 0 0 0 0 0 1
Fowble et al. [22] Conserve plus 50 1 0 0 0 0 0 0 0 1 0
Giannini et al. [23] BHR 350 4 3 0 0 0 0 0 0 1 0
Gravius et al. [24] Durom 82 2 1 0 0 0 0 0 0 0 1
Gross et al. [25] Cormet 373 21 5 12 2 2 0 0 0 0 0
Heilpern et al. [26] BHR 113 4 1 2 0 0 0 0 0 1 0
Hing et al. [27] BHR 230 2 0 1 0 0 0 0 0 1 0
Hulst et al. [28] Conserve plus 643 45 0 5 0 0 0 0 0 0 0
Jameson et al. [29] ASR 214 12 4 0 0 0 0 0 0 2 0
Khan et al. [30] BHR 679 29 11 14 3 1 0 0 0 0 0
Killampalli et al. [31] Cormet 100 0 0 0 0 0 0 0 0 0 0
Kim et al. [32] Conserve plus 200 14 2 11 0 0 0 0 1 0 0
Klein et al. [33] ASR 115 13 4 3 0 0 0 5 1 0 0
Langton et al. [34] BHR and ASR 660 17 1 0 0 13 0 0 0 0 12
Larbpaiboonpong et al. [35] BHR 40 1 1 0 0 0 0 0 0 0 0
Lei et al. [36] Durom 90 1 1 1 0 0 0 0 0 0 0
Mackenzie et al. [37] BHR 499 0 0 0 0 0 0 0 0 0 0
Madadi et al. [38] Cormet 52 6 3 3 0 0 0 0 0 0 0
Madhu et al. [39] BHR 117 8 5 0 1 0 0 0 0 2 0
Malhotra et al. [40] ASR 32 1 1 0 0 0 0 0 0 0 0
Marker et al. [41] Conserve plus 361 23 13 6 0 0 0 2 0 0 2
Marulanda et al. [42] BHR 230 3 1 0 0 0 1 0 0 0 1
McAndrew et al. [43] BHR 180 3 3 0 0 0 0 0 0 0 0
McBryde [44] BHR 2123 48 13 9 4 0 0 2 7 6 3
McMinn et al. [45] BHR 3095 68 12 2 14 10 2 0 2 25 1
Mont et al. [46] Conserve plus 54 2 1 1 0 0 0 0 0 0 0
Mont et al. [47] Conserve plus 1016 54 27 24 0 0 0 0 0 0 3
Naal et al. [48] Durom 100 11 4 3 0 0 0 2 2 0 0
Ollivere et al. [49] BHR 463 13 3 0 1 7 2 0 0 0 0
Sandiford et al. [50] BHR 141 0 0 0 0 0 0 0 0 0 0
Siebel et al. [51] ASR 300 8 5 1 0 0 1 0 0 0 1
Smolders et al. [52] Conserve plus 38 1 0 0 0 0 0 0 0 1 0
Steffen et al. [53] BHR 610 23 12 4 2 0 2 0 2 0 1
Stulberg et al. [54] Cormet 337 24 8 15 0 0 1 0 0 0 0
Swank and Alkire [55] BHR 128 2 1 0 0 0 0 0 0 0 0
Takamura et al. [56] Conserve plus 500 41 6 26 1 0 1 1 0 0 4
Treacy et al. [57] BHR 2123 48 1 1 3 0 1 0 0 3 1
Vendittoli et al. [58] Durom 109 4 0 4 0 0 0 0 0 0 0
Wang et al. [59] Conserve plus 37 0 0 0 0 0 1 0 0 0 0
Witzleb et al. [60] BHR 300 6 1 1 2 0 0 1 1 0 0
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Fig. 6.

Fig. 6

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Distribution of complications

According to the GRADE recommendation system, the quality of these studies in terms of level of evidence was very low except for a randomised clinical trial where the quality of results reported was low [7]. We could only find long-term studies for three types of implants: BHR, Conserve Plus, and Cormet. For these implants revision rates seemed to fit the criteria for NICE benchmarks. The implant ReCap had excellent results at 2.9 years of mean follow-up. The randomised clinical trial comparing the results of the Durom implant with those of a THA reported a higher rate of revision for the resurfacing implant. However, the difference was not statistically significant. The ASR implant did not fulfill the NICE criteria in any study.

Discussion

It is interesting to compare the results from the different national registries.

The Nordic Arthroplasty Register Association [10] has three national registries: Danish, Swedish and Norwegian. The total number of total hip replacements performed between 1995 and 2007 has reached a figure of 280,201, of which only 0.5 % represented resurfacing [61]. The revision rate at two years was reported as 2.4 % for all resurfacing vs 1.1 % for conventional THA. The main complications for resurfacings outlined were fractures and aseptic loosening. The Nordic register also highlighted a survival rate significantly higher in those centres performing greater than 70 cases per annum (98.8 %) than those performing fewer (95.5 %).

Analysis of the Australian register by Prosser et al. [1] succeeded the one of Buergi et al. [62] and examined 12,093 hip resurfacings performed between 1999 and 2008. The results were compared with those of conventional THA performed during the same period. Analysis of the registry showed that women had a higher revision rate than men. However, after adjusting the size of the femoral component revision rates were similar. Femoral implants of less than 50 mm in size had a higher revision rate than if the diameter was greater than or equal to 50 mm. At eight years the cumulative percentage revision for resurfacing was 5.3 (range, 4.6–6.2) against 4.0 (range, 3.8–4.2) for THA. However, in patients with primary hip OA, who were aged less than 55 years with a femoral implant size greater than or equal to 50 mm, the cumulative percentage revision was 3.0 (range, 2.2–4.2). Furthermore, Amstutz et al. [10] and McBryde et al. [44] found themselves documenting similar results for implants of smaller head sizes of less than 50 mm. The type of implant seemed to have an influence on the results. Durom implants, ASR, Cormet 2000 HAP and Recap had a higher revision rate and higher risk of fractures; this was statistically significant in comparison to other implants. The implant with the lowest fracture rate was the BHR implant with a five-year rate of 1.2 % (range, 1.0–1.5) against 3 % for ASR (range, 2–5), 2 % for Durom (range, 1–4 ) and 3 % (range, 1–9) for Recap. After adjusting for possible confounding factors, it appeared that the differences were only related to the designs of implants and surgical technique when preparing the femoral head. Finally, the registry highlighted that dysplastic hips were at a higher risk of revision.

Analysis of the English register was made by McMinn et al. [63] and included 283,365 procedures with a mean follow up of 3.6 years (range, 0.01–9.7). The objective of this analysis was unlike other registries, not only to study the revision rates after adjustment (with sex, age, size of implants, ASA / American Society of Anesthesiologists grade) but also to study the mortality rate. After adjusting for all known risk factors for revision surgery, mortality in men was statistically lower for the BHR implant in comparison to the uncemented THA group. The authors concluded for every 23 cases (males), there will be one less death in the BHR group in comparison to the cemented THA group at six years follow up.

In our review the percentage of studies that met the NICE criteria was 69.8 %. The average survival rate in these studies was significantly higher than the national registries. One explanation for this difference is that these studies are often single-operator led being experienced surgeons themselves. The most important series highlighted are those from design centres, which probably introduces a confounding factor.

However, analysis of records despite the large number of prosthesis is not provided to overestimate the information they provide. Indeed there are many confounding factors and bias that can lead to misinterpretation of the results.

First, record completeness is not guaranteed. So if the data collection seems close to 95 % for northern registers, it would be only 30 % for British records [64].

Second, the failure criteria is often the revision of the implant for whatever reason. This criteria is not necessarily impartial. This is because the sensitivity of the revision rate for clinical failure (insufficient functional score) is not identical between a resurfacing implant and a conventional total hip replacement. For example, as for knee arthroplasties, for hips with a poor functional outcome (HHS <30), only 12 % of THA may have been revised, as compared to 63 % of resurfacing with a similar score [63–65]. This calls into question the use of the revision rate for objectively comparing these two types of implants.

Third, the records do not account for the learning curve associated with the use of new implants [41, 66, 67]. Indeed for the implants on the market for over ten years there is no implication of a learning curve within the data held in the registries.

Finally, essential information is often missing: history of the patients, the ASA score, radiographic positioning of the implants, the presence of osteolysis, etc. This information is vital to determine the cause of failure, groups at risk and to compare similar groups of patients after adjustment for these criteria.

In conclusion, this review of the literature emphasises the importance of certain parameters that can improve the results of resurfacing. The type of implant seems to play an important role as does patient selection. This should be based more on the expected size of the implant rather than the gender. Finally, it is clear that the resurfacing implants require a significant learning curve and implants are less “tolerant” than conventional THA, particularly for the orientation of the acetabular component [44, 61, 68].

Acknowledgments

Conflict of interest

None.

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