SAN FRANCISCO, California—Resurfacing is emerging as a strategy to help younger arthritis patients safely defer total hip replacement (THR), according to experts speaking in a press conference at the 75th annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).¹

Panelist Tom Schmalzried, MD, noted “lifestyle preservation is a very important part of our care today.” He showed a video provided by a satisfied Santa Cruz patient with resurfaced hips who was surfing the waves.

Still invasive, but better range of motion

‘Resurfacing’ is something of a misnomer, as an implant is still used in the procedure. “This technology is not trivial,” said William Maloney, MD, professor of surgery and chair of the department of orthopaedic surgery at Stanford University, California, but the femur bears a much smaller cap and guide stem with the resurfacing device, and the socket preserves more of the patient’s own tissue. In addition, resurfacing is nearly as invasive as THR and requires similar healing time. Nonetheless, resurfacing gives patients a better range of motion, some proponents say.

Robert Trousdale, professor of orthopaedics at the Mayo Clinic, Rochester, Minnesota, noted that both procedures have risks and benefits. The femoral neck can still break with resurfacing, and the procedure removes more bone at the socket. “Patients’ perceptions are completely out of kilter with reality,” Dr. Trousdale said, blaming this on “poor communication” from doctors, the media, and the Internet. He emphasized that there is a learning curve for the resurfacing procedure and pin placement of the implant is crucial. “In properly selected patients,” he said, “the benefits outweigh the pitfalls.”

A prior version of hip resurfacing technology failed and was withdrawn from the market. Dr. Maloney said there are still patients and physicians who remember the fallout and they might be cautious to embrace the latest resurfacing technique.

Experts recommend early resurfacing for younger patients

Dr. Schmalzried, associate director of the joint replacement institute at St. Vincent Medical Center in Los Angeles, California, said, “it’s better if the disease process is interrupted earlier,” by resurfacing the hip in younger people. The risk of breaking a hip for a white woman in her 80s is 30%, Dr. Schmalzried noted. “This factors into the total risk-benefit profile for a patient,” as the resurfacing procedure does not remove the possibility to fracture the hip.

“A lot of women come in and ask for it,” said Paul Lachiewicz, MD, a professor of orthopaedics at the University of North Carolina, Chapel Hill, but only larger women with good bone stock are appropriate candidates for resurfacing, the panelists, agreed. Dr. Schmalzried concurred, “Patients have gotten very proactive about their health care. There are surgeons who will succumb to patient pressure, and that will become a black eye on the procedure” of resurfacing, he predicted.

You can always go to the full implant later

“The results of a good THR are really good,” Dr. Schmalzried said, “so you have to get something from resurfacing that you don’t get” from a total hip implant. However, he disagreed with some proponents who say that range of motion with resurfacing is better than THR, but the “active patients feel that resurfacing will give a cushion. You can always go to the full implant” later.

Paul E. Beaulé, MD, associate professor at the University of Ottawa and head of adult reconstruction services for the Ottawa Hospital, said that the prior resurfacing implant shed plastic debris and led to massive bone resorption. The new implant for resurfacing has metal-to-metal surfaces and has been in use in Europe since the late 1980s. The amount of cement used on the femur will affect the longevity, Dr. Beaulé noted, “surgeons need to refamiliarize themselves with this.”

The panelists agreed that prospective trials that blind patients to the type of implant they receive will reveal the facts, as patients’ perception about their implant type will be eliminated.

“We hope this [resurfacing] will be the last hip replacement, but for these active patients, we [just] don’t know,” Dr. Maloney said. Total hip and knee replacements together are Medicare’s biggest expense.

Reference

1. Getting hip-to-hip surgery: resurfacing and replacement. Presented at: AAOS 2008 meeting; March 6, 2008; San Francisco, Calif. Press conference.