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NYMD Panelist: All About Hip Resurfacing

Hip resurfacing is all the rage in the orthopedic community these days. In fact, I had four different hospitals pitch me stories on it in the last year, independent of one another.

But is it right for everyone with chronic, debilitating hip problems? NYMD News panelist Dr. William Macaulay, attending orthopedic surgeon at New York Presbyterian Hospital/Columbia and director of Columbia's Center for Hip and Knee Replacement, has the answers below and after the break.

By William Macaulay, M.D.

You just turned 40 or 50. Your mind tells you you’re younger, but you feel older because you have real hip pain that won’t quit. You limp everyday. You do a little research and come across a new procedure called total hip resurfacing. Then you wonder: Is this the right procedure for me?

I hear the same story over and over from my patients. Looking for a solution to their hip pain, they have stumbled upon total hip resurfacing, which was approved for use in the U.S. in May of 2006. While many patients are ideal candidates for resurfacing, often I must inform them that hip resurfacing is not for everyone.

Hip resurfacing is not a new concept. Older, less successful versions of hip resurfacing came and went between the 1930s and 1980s, which included materials such as glass, plastic and stainless steel. These implants eventually failed under normal activity requirements. Advances in metallurgy and refinements in surgical technique have brought resurfacing back to the foreground of hip surgery.

Today, total hip replacement remains the gold standard, especially for patients over the age of 60 or 65 with severe, debilitating arthritis of the hip. However, for the younger and more active hip arthritis patient, the long-term success of THR remains a concern. Scandinavian hip registries (the U.S. does not yet have one) have shown that active total hip replacement patients under the age of 55 have a 15% to 20% chance of requiring a re-operation within 10 years.

As a 40 or 50 year old with severe hip pain, arriving at surgical intervention as your last resort, which option do you choose? As with most things, there are pros and cons to each.

The benefit of hip resurfacing is suggested by its name. The top of the thigh bone is preserved by reshaping and capping with metal instead of replaced, as is the case with traditional hip replacements with a metal spike driven down the inside of the thigh bone.

Bone preservation is appealing. However, it comes at a cost. Reshaping the head (and working around it to seat the socket) makes resurfacing technically more difficult and lengthy. Surgeons require extra training to do this procedure well because it historically has not been taught in training programs in the U.S.

Patient indications for resurfacing are extremely important. Typical candidates will suffer from hip pain due to osteoarthritis, hip dysplasia (shallow "socket"), or avascular necrosis (bone death) and will have a level of high activity. Modern hip resurfacing involves cobalt chromium alloy (a specific wear-resistant metal) articulation. Due to the unknown potential problems associated with the release of small metal particles into the body (generally simply removed from the body in urine) which scrape off at the surface, resurfacing is typically not recommended for people with kidney problems or women who will bear children. Many studies have been performed to show that this metal is not particularly harmful, but this data cannot be considered conclusive. Additionally, strong bone is a requirement for hip resurfacing. This determination of bone strength is usually made during the surgery after the thigh bone is reshaped. If the bone is too soft or contains a large defect, total hip replacement is recommended.

In summary, the decision to proceed with a hip resurfacing should be made with the advice of a sub-specialized orthopedic surgeon. It is important for patients to understand that patients with successful hip resurfacings have specific characteristics. As a surgeon who bases his practice on evidence-based medicine, I remain skeptical until we have results that go beyond 20 years. Despite this healthy skepticism, it is impossible to ignore the elation of my young active patients who have quickly returned to the high activity that they so dearly missed.

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