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Unlabelled: A bone-conserving prosthetic solution, such as hip resurfacing arthroplasty, is desirable for patients with osteonecrosis (ON) of the femoral head because of their young age. However, many surgeons are reluctant to perform hip resurfacing for ON because of large femoral head defects. To ascertain whether this reluctance is warranted, we determined the mid- to long-term effects of ON on the survivorship, radiographic implant fixation, and disease-specific and quality-of-life scores of hip resurfacing. We compared the results of metal-on-metal resurfacing performed for ON of the hip (including large lesions) with those of resurfacing performed for other causes. The ON group had 70 patients (85 hips) and the control group 768 patients (915 hips) including all other etiologies operated on during the same period. The ON group was younger and had a greater incidence of femoral defects, a smaller component size, and a lower body mass index, three variables previously shown to reduce survivorship in hip resurfacing. We observed no difference in survivorship between the ON group and the control group even after adjusting for head size, body mass index, and defect size. Pain relief, walking, and function scores were comparable postoperatively. The activity level was lower in the ON group. Our data suggest ON is not a contraindication for resurfacing even with large femoral head defects.Level Of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The effect of obesity on the outcomes of metal-on-metal resurfacing arthroplasty is not currently known. In this study, we assessed the influence of body mass index on the survival of a metal-on-metal hybrid hip resurfacing prosthesis by comparing the clinical results of patients with a body mass index of >or=30 with those of patients with a body mass index of <30.Methods: We retrospectively reviewed our registry to identify all patients who had been followed for at least two years after a metal-on-metal hip resurfacing arthroplasty, and we divided those patients according to whether they had had a body mass index of >or=30 (the study group) or <30 (the control group) at the time of the surgery. One hundred and twenty-five patients (144 hips) with an average weight of 104.6 kg and an average body mass index of 33.4 were included in the study group, and 531 patients (626 hips) with an average weight of 78.3 kg and an average body mass index of 25.4 were included in the control group. We compared the clinical results (UCLA [University of California at Los Angeles] and Harris hip scores, SF-12 [Short Form-12] survey results, and complication rates), radiographic results, and prosthetic survival rates of the two groups.Results: There was no significant difference postoperatively between the groups with regard to the UCLA pain or walking scores or the mental component score of the SF-12. However, the UCLA function and activity scores were lower in the study group than in the control group (9.2 compared with 9.6 points [p = 0.001] and 7.1 compared with 7.6 points [p = 0.002], respectively). The control group had a significantly higher postoperative physical component score on the SF-12 (51.4 points compared with 49.3 points in the study group, p = 0.01) and postoperative Harris hip score (93.8 compared with 90.6 points, p = 0.0003). Two hips (1.4%) were revised in the study group. In contrast, thirty-one hips (5.0%) were converted to a total hip replacement in the control group; twenty of the thirty-one were revised because of loosening of the femoral component. The five-year survivorship of the hip prostheses was 98.6% in the study group and 93.6% in the control group (p = 0.0401). When the entire cohort was divided into three groups according to whether the body mass index was <25, 25 to 29, or >or=30, the risk of revision was found to have decreased twofold from one group to the next as the body mass index increased (p = 0.013). No acetabular component loosened in either group. The average diameter of the femoral component was 48.3 mm in the study group and 46.8 mm in the control group (p = 0.0001). There were no revisions for any reason and no radiolucencies were observed in a subset of twenty-seven patients with a body mass index of >or=35.Conclusions: Metal-on-metal resurfacing hip arthroplasty is performing well in patients with a high body mass index, although the function scores are reduced compared with those for patients with a body mass index of <30. The protective effect of a high body mass index on survivorship results may be explained by a reduced activity level and a greater component size in this patient population. [ABSTRACT FROM AUTHOR]

Recently, improved metal-on-metal bearing technology has led to the reemergence of resurfacing as a reasonable option for total hip arthroplasty. During the course of a prospective multicenter FDA-IDE evaluation of metal-on-metal total hip resurfacings, we modified our indications and emphasized surgical technique where the femoral surface area was small due to femoral cysts and small component size. We assessed the influence of these changes on complication rates in the first cohort of 292 patients and the second of 724, and then compared these outcomes in the second cohort with historical reports of resurfacing. We had a minimum followup of 24 months (mean, 33 months; range, 24-60 months). After changes were made in the indications and technique, the overall complication rate decreased from 13.4% to 2.1% with the femoral neck fracture rate reduced from 7.2% to 0.8%. The outcomes of the second cohort compare with modern-day resurfacing devices and appear superior to historical results. The data suggest patients should be carefully selected and technique optimized to reduce complications. Long-term followup is required to see if these promising results will be maintained. [ABSTRACT FROM AUTHOR]

Background: Modern hip resurfacing implants may increase stability and preserve more bone than conventional total hip arthroplasty. The purpose of this retrospective study was to analyze the mid-term results in a consecutive series of middle-aged patients with developmental dysplasia of the hip treated with hybrid resurfacing joint arthroplasty.Methods: Metal-on-metal hip resurfacing was performed in fifty-one patients (fifty-nine hips), forty-two of whom were female and nine of whom were male. The average age at the time of surgery was 43.7 years. Radiographic and clinical data were collected at six weeks, at three months, and at yearly follow-up visits. Seven hips had Crowe type-II developmental dysplasia of the hip and fifty-two had type-I.Results: The follow-up period ranged from 4.2 to 9.5 years (average, 6.0 years). Initial stability was achieved in all but three hips. The clinical outcomes, as rated with the University of California at Los Angeles (UCLA) hip score, improved significantly compared with the preoperative ratings. On the average, the pain rating improved from 3.2 to 9.3 points; the score for walking, from 6.0 to 9.7 points; the score for function, from 5.7 to 9.6 points; and the score for activity, from 4.6 to 7.3 points (all p = 0.0001). The mean Short Form-12 (SF-12) mental score increased from 46.6 to 53.5 points, and the mean SF-12 physical score increased from 31.7 to 51.4 points (both p < 0.0001). The mean postoperative Harris hip score was 92.5 points. On the average, the range of flexion improved from 106 degrees to 129.6 degrees ; the abduction-adduction arc, from 41.9 degrees to 76.9 degrees ; and the rotation arc in extension, from 32.1 degrees to 84.8 degrees (all p = 0.0001). Four patients delivered a total of six healthy babies since the time of implantation of the prosthesis. Radiographic analysis showed a decrease in the mean body weight lever arm from 118.5 mm preoperatively to 103.9 mm postoperatively (p = 0.007). There were five femoral failures requiring conversion to a total hip arthroplasty. One hip showed a radiolucency around the metaphyseal femoral stem. There were no complete acetabular radiolucencies, and all sockets remained well fixed.Conclusions: The mid-term results of metal-on-metal resurfacing in patients with Crowe type-I or II developmental dysplasia of the hip were disappointing with respect to the durability of the femoral component. However, the fixation of the porous-coated acetabular components without adjuvant fixation was excellent despite incomplete lateral acetabular coverage of the socket. More rigorous patient selection and especially meticulous bone preparation are essential to minimize femoral neck fractures and loosening after this procedure. [ABSTRACT FROM AUTHOR]

Background: Following the reintroduction of metal-on-metal articulating surfaces for total hip arthroplasty in Europe in 1988, we developed a surface arthroplasty prosthetic system using a metal-on-metal articulation. The present study describes the clinical and radiographic results of the first 400 hips treated with metal-on-metal hybrid surface arthroplasties at an average follow-up of three and a half years.Methods: Between November 1996 and November 2000, 400 metal-on-metal hybrid surface arthroplasties were performed in 355 patients. All femoral head components were cemented, but only fifty-nine of the short metaphyseal stems were cemented. The patients had an average age of forty-eight years, 73% were men, and 66% had a diagnosis of osteoarthritis. Clinical and radiographic follow-up was performed at three months postoperatively and yearly thereafter.Results: The majority of the patients returned to a high level of activity, including sports, and 54% had activity scores of >7 on the University of California at Los Angeles activity assessment system. Kaplan-Meier survivorship curves demonstrated that the rate of survival of the components at four years was 94.4%. For patients with a surface arthroplasty risk index score of >3, the rate of survival of the components at four years was 89% compared with a rate of 97% for those with a score of Conclusions: The preliminary experience with this hybrid metal-on-metal bearing is encouraging. Optimal femoral bone preparation and component fixation are critical to improving durability. The metal-on-metal hybrid surface arthroplasty is easily revised to a standard femoral component if necessary. [ABSTRACT FROM AUTHOR]

Background: Metal-on-metal hip resurfacing arthroplasty (MMHRA) is typically used in young and active patients because they have the most to gain from this bone-preserving procedure. However, there is very little long-term data on the performance of MMHRA in patients 65 years of age or older because of the efficacy of conventional total hip arthroplasty in this patient population., Methods: 109 patients (124 hips) age ⩾65 years were treated with Conserve Plus MMHRA. There were 83 male and 26 female patients. Their mean age at surgery was 69.5 (range 65-83) years. UCLA hip scores, SF-12 quality of life score were collected at follow-up visits. Radiographic and survivorship analyses were performed., Results: SF-12 scores and UCLA scores were maintained over time except for a small decrease in activity. 4 patients underwent revision surgery. The 15-year Kaplan-Meier survivorship of the cohort was 93.7%. All revisions surgeries were successful at a mean follow-up time of 113 (range 30-218) months. Unusual radiographic findings from our previous publication did not progress over time except for 1 hip that showed a complete radiolucency around the acetabular component., Conclusions: Our results clearly show that HRA is a viable prosthetic solution with many advantages for all active patients, regardless of their age at the time of surgery.

Aims: Adverse local tissue reactions associated with abnormal wear considerably slowed down the general use of metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), now limited to a few specialized centres. In this study, we provide the clinical results of 400 consecutive MoM HRAs implanted more than 20 years ago in one such centre., Methods: A total of 355 patients (400 hips) were treated with Conserve Plus HRA between November 1996 and November 2000. There were 96 female (27%) and 259 male patients (73%). Their mean age was 48.2 years (SD 10.9). The University of California, Los Angeles (UCLA) hip scores and 12-item Short Form Survey (SF-12) quality of life scores were reported. Survivorship was assessed using Kaplan-Meier analyses., Results: The mean follow-up was 16.5 years (0.1 to 24.0), including 34 patients (37 hips) who died. The mean UCLA hip scores were 9.3 (2 to 10), 9.1 (3 to 10), 9.0 (3 to 10), and 6.9 (2 to 10) for pain, walking, function, and activity, respectively. The mean SF-12 scores were 48.4 (16.0 to 62.1) for the physical component and 48.5 (10.5 to 66.5) for the mental component, and did not differ from those of the general population of the USA. A total of 60 hips in 55 patients were revised. Using revision for any indication as the endpoint, the Kaplan-Meier survivorship was 83.5% at 20 years. A diagnosis of developmental dysplasia (hazard ratio (HR) 2.199 (95% confidence interval (CI) 1.140 to 4.239); p = 0.019) and a low BMI (HR 0.931 (95% CI 0.873 to 0.994); p = 0.032) were risk factors for revision. Female sex was a risk factor only because of hip dysplasia and small component size. There were no cases of metal sensitivity associated with revision surgery. Radiological analysis showed persistent fixation in all but one hip., Conclusion: The 83.5% 20-year survivorship of this initial series surpasses that of total hip arthroplasties in use 20 years ago in these young patients, suggesting satisfactory lifelong durability of the device for almost all of the remaining patients. Cite this article: Bone Joint J  2021;103-B(7 Supple B):25-32.

Aims: Hip resurfacing arthroplasty (HRA) is typically indicated for young and active patients. Due to the longevity of arthroplasty, these patients are likely to undergo revision surgery during their lifetime. There is a paucity of information on the long-term outcome of revision surgeries performed after failed HRA. The aim of our study was to provide survivorship data as well as clinical scores after HRA revisions., Methods: A total of 42 patients (43 hips) were revised after HRA at our centre to a variety of devices, including four HRA and 39 total hip arthroplasties (THAs). In addition to perioperative complications, University of California, Los Angeles (UCLA) hip scores and 12-Item Short-Form Health Survey questionnaire (SF-12) quality of life scores were collected at follow-up visits after the primary HRA and after revision surgery., Results: The mean follow-up time after revision surgery was 8.3 years (0.3 to 19.1). The mean UCLA pain and function scores post-revision were comparable with the best scores achieved by the patients after the index HRA, but UCLA activity scores were lower after revision. SF-12 physical component scores were comparable between timepoints, but the mental component score decreased after revision. Six patients underwent unilateral re-revision surgery at a mean follow-up time of 7.8 years (0.3 to 13.7). Using the time to any re-revision as endpoint, the Kaplan-Meier survivorship was 85.3% at 13 years., Conclusion: Patients undergoing revision after HRA can expect to achieve function and quality of life similar to their best after their primary surgery, while the risk of re-revision is low. Cite this article: Bone Joint J 2020;102-B(10):1289-1296.

Background: The need for revision surgery after hip resurfacing arthroplasty (HRA) is more prevalent for women than for men. However, there is a paucity of information to explain this observation. We aimed (1) to determine sex-specific risk factors leading to revision surgery; and (2) to correlate these risk factors to the dominant modes of failure of HRA., Methods: 1101 patients (1375 consecutive hips) including 292 women (355 hips) and 809 men (1020 hips) with a mean age of 51.3 years were included regardless of bone quality. The contact patch to rim distance was computed., Results: A contact patch to rim (CPR) distance of ⩽7 mm, an aetiology of developmental dysplasia, a postoperative abduction-adduction arc of ⩾95°, and a metaphyseal stem left uncemented were risk factors associated with revision surgery for female patients, while a CPR distance of ⩽10 mm, a component size of ⩽46 mm, an age at surgery of ⩽55 years, and an early femoral preparation technique were risk factors for male patients. Hips with no risk factors from the female group had a survivorship of 98.7% at 15 years, matching or exceeding the results of all male subgroups. However the risk factors in the female group increased the risk of revision much more than in the male group., Conclusions: In the absence of risk factors, the survivorship of HRA in female patients is equal to that of males. Many female patients can safely benefit from HRA by excluding severe dysplasia and optimising surgical technique.

Background: Hip resurfacing arthroplasty (HRA) typically uses a hybrid design (cemented femoral component and cementless acetabular shell) but has recently been performed with fully cementless components. There is a paucity of information on the clinical performance of these cementless designs., Methods: The UCLA clinical scores, SF-12 quality of life scores, complication rates, survivorship and radiographic signs of loosening or gross stress shielding of 39 hips (39 male patients) implanted with cementless HRA were compared with those of 40 hips (37 male patients) implanted with hybrid HRA during the same time frame., Results: There were no significant differences in postoperative clinical and quality of life scores, complication rates, or radiographic signs of loosening between the 2 groups. The 5-year Kaplan-Meier survivorship was 97.2% for the cementless group and 100% for the hybrid group. This difference was not significant ( p = 0.3694). There were no femoral component failures in any of the 2 groups., Conclusions: At a mean follow-up of 6 years, there is no tangible difference between the performance of cementless HRA compared to hybrid HRA. The absence of learning curve associated with this device and the potential for better preservation of femoral neck bone mineral density suggest that this technology is well suited for young patients with good bone quality seeking to resume an active lifestyle including high-impact activities.

Aims: In previous studies, we identified multiple factors influencing the survivorship of hip resurfacing arthroplasties (HRAs), such as initial anatomical conditions and surgical technique. In addition, the University of California, Los Angeles (UCLA) activity score presents a ceiling effect, so a better quantification of activity is important to determine which activities may be advisable or detrimental to the recovered patient. We aimed to determine the effect of specific groups of sporting activities on the survivorship free of aseptic failure of a large series of HRA., Patients and Methods: A total of 661 patients (806 hips) representing 77% of a consecutive series of patients treated with metal-on-metal hybrid HRA answered a survey to determine the types and amounts of sporting activities they regularly participated in. There were 462 male patients (70%) and 199 female patients (30%). Their mean age at the time of surgery was 51.9 years (14 to 78). Their mean body mass index (BMI) was 26.5 kg/m 2 (16.7 to 46.5). Activities were regrouped into 17 categories based on general analogies between these activities. Scores for typical frequency and duration of the sessions were used to quantify the patients' overall time spent engaging in sporting activities. Impact and cycle scores were computed. Multivariable models were used., Results: We found no association between any category of activity and a decrease in survivorship. Impact and hip cycle scores also failed to show any association with revision for aseptic failure or wear., Conclusion: Return to sporting activities after surgery is safe for patients treated with well-designed and well-implanted HRA. Cite this article: Bone Joint J 2019;101-B:1186-1191.

Aims: This study presents the long-term survivorship, risk factors for prosthesis survival, and an assessment of the long-term effects of changes in surgical technique in a large series of patients treated by metal-on-metal (MoM) hip resurfacing arthroplasty (HRA)., Patients and Methods: Between November 1996 and January 2012, 1074 patients (1321 hips) underwent HRA using the Conserve Plus Hip Resurfacing System. There were 787 men (73%) and 287 women (27%) with a mean age of 51 years (14 to 83). The underlying pathology was osteoarthritis (OA) in 1003 (75.9%), developmental dysplasia of the hip (DDH) in 136 (10.3%), avascular necrosis in 98 (7.4%), and other conditions, including inflammatory arthritis, in 84 (6.4%)., Results: The mean follow-up time was 10.5 years (1 to 20). Using revision for any reason as the endpoint, the overall survivorship at 15 years was 89.4% (95% confidence interval (CI) 86.8 to 91.4). There was a substantial increase between the first and second generation of surgical technique (86.6% vs 90.1%; p = 0.05). Men with idiopathic OA had a 15-year survivorship of 94.5% and women, 82.2% (p = 0.001); gender was not a risk factor after stratification by component size and aetiology. Using revision for excessive wear (ion levels > 7 µg/l associated with symptoms or adverse local tissue reactions) as the endpoint, the 15-year survivorship was 98.5%. Risk factors for revision for all modes of failure were an underlying pathology of hip dysplasia, a contact patch to rim (CPR) distance of 7 mm or less, an age at surgery of 55 years or less, and a femoral component size of 46 mm or less. Specific risk factors for aseptic failure of the femoral component were early surgical technique, a cementless metaphyseal stem, and a body mass index of 24 kg/m 2 or less., Conclusion: HRA is a viable concept; metal-on-metal bearings are well suited for this procedure when a well-designed device is properly implanted. The best results were obtained in men with OA, but survivorship was better for other underlying pathologies and for women after changes were made to the technique of implantation. Lifetime durability is a possible outcome for many patients despite a high level of activity. Cite this article: Bone Joint J 2018;100-B:1424-33.

Background: Adverse local tissue reactions (ALTR) have been associated with the use of metal-on-metal (MoM) bearings and the monitoring of cobalt (Co) and chromium (Cr) ion levels in blood or serum may be the best way to evaluate in vivo the wear of these bearings. However, the relationship between Co and Cr ion concentrations and the formation of ALTR remains unclear., Methods: We investigated the relationship between ALTR and serum Co and Cr ion levels and identified the clinical factors influencing the formation of ALTR in patients treated with MoM hip resurfacing arthroplasties. 228 patients with unilateral Conserve® Plus MoM hip resurfacing had serum metal ion studies performed more than 1 year after surgery. Metal artifact reduction sequence magnetic resonance imaging (MARS MRI) was performed on subjects at risk for ALTR as determined by a screening protocol., Results: 12 patients had ALTR. Logistic regression showed a strong association of ALTR with elevated ion levels and with low (<10 mm) contact patch to rim distance., Conclusions: MoM bearings require enough functional coverage of the socket by design and then precise implantation to maximise functional coverage of the femoral ball, enhance lubrication, and avoid edge-loading wear.

Aims: A contact patch to rim (CPR) distance of < 10 mm has been associated with edge-loading and excessive wear. However, not all arthroplasties with a low CPR distance show problems with wear. Therefore, CPR distance may not be the only variable affecting the post-operative metal ion concentrations., Patients and Methods: We used multiple logistic regression to determine what variables differed between the patients who had high and low cobalt (CoS) and chromium (CrS) serum ion concentrations within a cohort of patients with low (< 10 mm) CPR distances. A total of 56 patients treated with unilateral hip resurfacing arthroplasty (HRA) had CoS and CrS ion studies performed more than one year after surgery. The mean age of the patients at the time of surgery was 51.7 years (29 to 70), with 38 women (68%) and 18 men (32%)., Results: It was seen that 47 patients had low ion levels (< 7µg/L) and nine had high ion levels (≥ 7µg/L). We found increased risks of high wear with decreasing CPR distance., Conclusion: The use of CPR distance measurements to predict hips at risk for elevated wear is needed for all patients with HRA. We recommend that patients with low CPR distances have at least one serum ion study performed while patients with CPR distance > 10 mm do not need routine ion studies. We believe that patients with low CPR distance and low ions do not need repeat ion studies unless the patient becomes symptomatic or has substantial radiographic changes. Cite this article: Bone Joint J 2017;99-B:865-71., (©2017 The British Editorial Society of Bone & Joint Surgery.)

The effect of previous conservative surgeries on the outcome of metal-on-metal hip resurfacing arthroplasty (HRA) has not been studied. This study compared postoperative clinical scores and survivorship results of hips with and without previous osteotomies in a population of patients who underwent HRA. A total of 1101 patients (1375 hips) with a mean age of 51.3 years at the time of surgery underwent HRA at a single center. Sixty-nine patients had undergone prior surgery on the operated hip including 14 osteotomies (1 pelvic, 6 femoral, and 7 combined pelvic and femoral osteotomies). Mean follow-up was comparable for patients with prior osteotomy and patients in the control group (101 months vs 96 months, P=.6916); however, patients with prior osteotomies were much younger at the time of surgery (34 years vs 51 years, P=.0001). Kaplan-Meier survival estimates were calculated, and the Cox proportional hazard ratio was used to adjust for the covariates that differed between the 2 groups and affected the survivorship of hip resurfacing. Patients who underwent prior osteotomy showed lower pain and activity scores. In addition, patients who underwent prior osteotomy had a greater chance of revision than the rest of the cohort (hazard ratio, 3.87; 95% confidence interval, 1.54-9.68; P=.004). For patients in whom the natural anatomy or the bone quality of the hip has been severely altered by a prior osteotomy, HRA may be contraindicated if good component fixation cannot be achieved and hip biomechanics restored. [Orthopedics. 2017; 40(4):e609-e616.]., (Copyright 2017, SLACK Incorporated.)

With metal-on-metal (MoM) bearings, fluid film lubrication is disrupted when the contact patch area between the femoral head and the cup is close to the edge of the acetabular component, making the calculation of the contact patch to rim (CPR) distance a key variable in the study of the performance of MoM bearings. A few research centers have used models of varying complexity to calculate the CPR distance and determine its relationship with assessments of component wear. In this review, we aimed to summarise the current knowledge related to the application of CPR distance calculations in the study of in vivo performance of MoM bearings. Our systematic search of the US National Library of Medicine yielded 9 relevant publications in which 3 different models were used for the computation of the CPR distance. The 3 models show different levels of complexity and their use is mainly dependent upon the size of the subject sample and the nature of the data collected as a dependent variable. The studies reviewed consistently showed a strong inverse correlation between CPR distance and wear or metal ion levels suggesting that any study aiming to determine the risk factors for MoM hip devices needs to include an assessment of CPR distance. Cup anteversion can be measured reliably with various tools and should not be an obstacle to the use of this essential variable that is CPR distance.

There is a paucity of information regarding the clinical performance of the fully cementless metal-on-metal hip resurfacing designs. We compared the biomechanical reconstruction between the two hips of a group of patients treated with a hybrid resurfacing design on one side and a new, fully cementless version of the same resurfacing design on the other side.We retrospectively identified 20 patients with a hybrid hip resurfacing on one side and a fully cementless device on the contralateral side. The cemented femoral components were implanted with a target angle stem to shaft angle of 140° while the cementless femoral components were implanted with the aim to replicate the natural neck to shaft angle.No significant differences were observed post-operatively in femoral offset or leg length despite implantation with a larger metaphyseal stem to femoral shaft angle in the hybrid group. Both hybrid and cementless designs provide similar biomechanical reconstructions.

Background: Idiopathic osteoarthritis (OA) is a common diagnosis leading to hip arthroplasty. Patients undergoing unilateral hip arthroplasty often wonder whether their other hip will follow the same path as the one that was operated on, and if so, when? There also are limited data available to predict from AP radiographs which contralateral hips will have OA develop and which will not., Questions/purposes: We sought (1) to determine the incidence of contralateral osteoarthritic degeneration in a group of patients who were treated with unilateral hip arthroplasty; and (2) to identify clinical and radiographic features associated with the development of contralateral OA., Methods: Between 1998 and 2010, we performed 398 hip arthroplasties on patients with unilateral primary hip OA, who at the time of surgery did not have any symptoms in the contralateral hip. Of those, 367 (92%) had a minimum 2-year radiographic followup (mean, 11 years; range, 2-17 years). The 31 patients dropped from the study for lack of radiographic followup had comparable preoperative features as the study group. We performed a radiographic analysis on the baseline AP radiographs to see what factors were associated with arthritis progression, and we performed Kaplan-Meier survivorship analysis with contralateral hip pain and contralateral THA as the endpoints., Results: Kaplan-Meier survival estimates indicated that 10 years after the baseline evaluation, 59% (95% CI, 53%-65%) of the patients remained free of symptoms on the contralateral hip and 81% (95% CI, 75%-85%) remained free of an arthroplasty on the contralateral hip. Sex, age, weight, or BMI were not associated with the development of OA on the contralateral hip with the numbers available. Reduced minimum joint space width (hazard ratio, 0.299; 95% CI, 0.237-0.378), low center-edge angle (hazard ratio, 0.941; 95% CI, 0.915-0.968), low head-to-neck ratio (hazard ratio, 1.555; 95% CI, 1.088-2.223), and the presence of osteophytes (hazard ratio, 1.453; 95% CI, 1.001-2.110) were associated with the development of contralateral OA. In hips with a center-edge angle greater than 25°, a head-to-neck ratio of 1.3 or less increased the chances of development of OA by 86% (hazard ratio, 1.857; 95% CI, 1.235-2.793)., Conclusions: The variables we studied can easily be assessed from an AP pelvis radiograph so physicians can predict the occurrence of contralateral OA and the need for future hip arthroplasty in their patients needing unilateral arthroplasty. However, the data available might have led us to underestimate the need for contralateral arthroplasty. Future studies with a prospective design should aim at completing the list of radiographic features associated with the development of OA by adding a review of lateral radiographs., Level of Evidence: Level IV, prognostic study.

Aims: Hip resurfacing arthroplasty (HRA) is an alternative to conventional total hip arthroplasty for patients with osteonecrosis (ON) of the femoral head. Our aim was to report the long-term outcome of HRA, which is not currently known., Patients and Methods: Long-term survivorship, clinical scores and radiographic results for 82 patients (99 hips) treated with HRA for ON over a period of 18 years were reviewed retrospectively. The mean age of the 67 men and 15 women at the time of surgery was 40.8 years (14 to 64). Patients were resurfaced regardless of the size of the osteonecrotic lesion., Results: The mean clinical follow-up was 10.8 years (2 to 18). The mean University of California, Los Angeles hip scores at the last follow-up were 9.3, 9.4, 9.2 and 6.8 for pain, walking, function and activity, respectively. A total of six hips underwent revision surgery, four for loosening of the femoral component and two for loosening of the acetabular component. Using any revision as an end point, the 15-year Kaplan-Meier survivorship was 90.3%. There were no wear-related failures. There were no femoral failures among the hips reconstructed with a cemented metaphyseal stem. A total of five hips showed narrowing of the femoral neck; all stabilised and remain asymptomatic, 21 showed signs of femoral neck impingement., Conclusion: To our knowledge, this is the first report of a series of HRA performed for ON with 15-year survivorship. Our data confirm that patients with advanced stages of ON of the femoral head are excellent candidates for HRA. Cite this article: Bone Joint J 2016;98-B:901-9., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Background: Cementing the metaphyseal stem during hip resurfacing surgery improves the initial fixation of the femoral component. However, there may be long-term detrimental effects such as stress shielding or an increased risk of thermal necrosis associated with this technique., Questions/purposes: We compared (1) long-term survivorship free from radiographic femoral failure, (2) validated pain scores, and (3) radiographic evidence of component fixation between hips resurfaced with a cemented metaphyseal stem and hips resurfaced with the metaphyseal stem left uncemented., Methods: We retrospectively selected all the patients who had undergone bilateral hip resurfacing with an uncemented metaphyseal stem on one side, a cemented metaphyseal stem on the other side, and had both surgeries performed between July 1998 and February 2005. Forty-three patients matched these inclusion criteria. During that period, the indications for cementing the stem evolved in the practice of the senior author (HCA), passing through four phases; initially, only hips with large femoral defects had a cemented stem, then all stems were cemented, then all stems were left uncemented. Finally, stems were cemented for patients receiving small femoral components (< 48 mm) or having large femoral defects (or both). Of the 43 cemented stems, two, 13, 0, and 28 came from each of those four periods. All 43 patients had complete followup at a minimum of 9 years (mean, 143 ± 21 months for the uncemented stems; and 135 ± 22 months for the cemented stems; p = 0.088). Survivorship analyses were performed with Kaplan-Meier and Cox proportional hazards ratios using radiographic failure of the femoral component as the endpoint. Pain was assessed with University of California Los Angeles (UCLA) pain scores, and radiographic femoral failure was defined as complete radiolucency around the metaphyseal stem or gross migration of the femoral component., Results: There were four failures of the femoral component in the press-fit stem group while the cemented stem group had no femoral failures (p = 0.0471). With the numbers available, we found no differences between the two groups regarding pain relief or radiographic appearance other than in patients whose components developed loosening., Conclusions: Cementing the metaphyseal stem improves long-term implant survival and does not alter long-term pain relief or the radiographic appearance of the proximal femur as had been a concern based on the results of finite element studies. We believe that patients with small component sizes and large femoral head defects have more to gain from the use of this technique which adds surface area for fixation, and there is no clinical downside to cementing the stem in patients with large component sizes., Level of Evidence: Level III, therapeutic study.

Introduction: Acetabular component loosening is a leading cause for revision after metal-on-metal hip resurfacing arthroplasty (MMHRA). We aimed to identify potential risk factors and determine radiographic signs associated with this mode of failure., Methods: From a series of 1375 hips treated with MMHRA, 21 (20 patients) underwent revision surgery secondary to aseptic loosening of the acetabular component and 6 patients had a radiographically loose acetabular component. A control group of 27 hips (26 patients) was selected among the patients that did not have a revision, and was matched for age, gender, component size and diagnosis., Results: Mean time to revision in the loosening group was 103.0 months and the mean time of follow-up in the control group was 161.4 months. We found greater activity levels, range of motion scores, and cup abduction angles in the loosening group. The centre-edge (CE) angle of Wiberg was 10° lower in the loosening group compared with the control group. In addition, 11 of the hips from the study group presented a sclerotic halo superior to the cup on the last radiograph vs. none in the control group. There was no difference in the prevalence of postoperative reaming gaps or radiographic signs of neck-cup impingement between the 2 groups., Discussion: Risk factors for acetabular loosening included hip dysplasia with low CE angle, and a large cup abduction angle. The patient's level of activity influences the appearance of symptoms and the time to revision. We recommend selecting patients with a sufficient CE angle and properly orienting the cup.

Hip resurfacing arthroplasty (HRA) presents several advantages over conventional total hip arthroplasty (THA), including conservation and preservation of bone, reduced risk of dislocation, easy replication of hip biomechanics and easy revision if needed. It is a particularly appealing procedure for young patients. HRA has been performed for over 40 years following the same technological advances as THA. The bearing material used by most designs is metal-on-metal (MoM), which has the best compromise between strength and wear properties. However, MoM HRA has a specific set of possible complications. Aseptic femoral failures were initially the most prevalent cause for revision but progress in patient selection and surgical technique seem to have resolved this problem. Wear-related failures (high metal ion levels and adverse local tissue reactions) are now the main concern, and are essentially associated with poor acetabular component design and orientation, to which MoM is more sensitive than other bearing materials. The concept of functional coverage is key to understanding how MoM bearings are affected by edge wear. Only a 3-D assessment of cup position (e.g., the contact patch to rim distance) provides the necessary information to determine the role of cup positioning in relationship with abnormal bearing wear.The concept of hip resurfacing is more valid today than ever as the age of the patients in need of hip arthroplasty keeps getting lower. The recent publication of several excellent long-term survivorship results suggests that selection of a well-designed resurfacing system and accuracy in the placement of the cup can achieve long-term durability.

Unlabelled: Liner cementation into a preexisting stable socket may reduce the morbidity of revision hip arthroplasty and preserve acetabular bone. However, the long-term outcomes of this technique remain unknown. The purpose of this report was to analyze the long-term results of a previously reported cohort of patients. Cementation of thirty-two liners (seventeen polyethylene and fifteen metal liners) into preexisting sockets was performed during revision hip arthroplasty, and the patients were followed for a minimum of two years. A retrospective chart review was performed to investigate the complications and survivorship. The mean duration of follow-up was 12.7 years (range, 2.1 to 19.1 years), with ten hips requiring rerevision at a mean of 6.4 years (range, 1.0 to 15.5 years). Nine patients experienced posterior dislocations, and two hips required rerevision for instability. Liner dissociation from the shell occurred in two patients. Survivorship analysis, with rerevision as the end point, demonstrated ten and fifteen-year survivorship of 77.3% and 68.8%, respectively. Dissociation of the cemented liner from the acetabular shell was an infrequent cause of failure despite long-term follow-up. Given the high rate of dislocations in this study, careful patient selection and surgical technique should be considered., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Metal-on-metal hip resurfacing (MOMHR) is an alternative to total hip replacement in young and active patients but little is known about the evolution of clinical outcome scores of hip resurfacing over time.The purpose of this study was 1) to assess the long-term evolution of UCLA hip scores and SF-12 Quality of life evaluations in a group of patients treated with hip resurfacing arthroplasty, 2) to determine whether the age of the patient at surgery influenced these outcome measurements, and 3) whether the changes in SF-12 scores are comparable with those of the general US population., Patient and Methods: A total of 100 patients with unilateral, unrevised, Charnley class A MOMHR were retrospectively selected for the study. UCLA and SF-12 scores were calculated preoperatively, short-term postoperatively, and beyond 10 years., Results: There was a decrease in the UCLA function and activity scores, and in the SF-12 physical scores between the short-term and the last follow-up at a minimum of 10 years. However, pain, walking, and SF-12 mental scores were maintained through the last follow-up. Furthermore, the SF-12 physical scores at last follow-up were comparable with those of the general US population while the mental scores were greater. There were no significant differences between the two age groups at any of the follow-up intervals for any outcome measurement., Conclusions: While there is a slight decline in physical function following hip resurfacing over time, pain relief, walking ability, and quality of life are maintained.

Highly cross-linked polyethylene (XLPE) has improved wear properties. This study reports the results of a small series of patients treated over 10 years ago with a metal-on-XLPE hip resurfacing.A total of 21 hips in 20 patients received a hip resurfacing with a cobalt-chromium metal femoral head and metal-backed acetabular cup lined with a XLPE insert and were retrospectively studied. Kaplan-Meier Survivorship was calculated.Five patients who had initial extreme cystic disease in the femoral head failed due to femoral loosening. Survivorship was 95.2% at 5 years and 81.0% at 10 years.We found that XLPE wear was not implicated in these failures, which were primarily attributed to poor bone quality of the femoral head, early bone preparation, cementing technique and excessive head reaming to near the neck diameter, necessitated for the implantation of a thick two-part socket.

There is concern regarding elevated metal ion levels in the blood during pregnancy and the potential fetal effects in women with metal-on-metal (MOM) implants. We obtained maternal and umbilical cord blood samples from 3 patients with a MOM hip arthroplasty and 7 control subjects without any metallic implants. Serum metal ion levels including chromium, cobalt, titanium, and nickel were tested using high-resolution sector-field inductively-coupled plasma-mass spectrometry. Mothers with MOM-bearing implants had significantly elevated levels of serum cobalt and chromium compared with control-group mothers, and umbilical cord blood from mothers with MOM implants also had significantly higher serum metal ion levels compared with control-group mothers. The results of this study show that circulating serum levels of metal ion degradation products from MOM bearings cross the placenta and expose the fetus to metal ions. However, the placenta exerts a modulatory effect on cord blood, resulting in decreased levels compared with maternal samples (approximately 15% of maternal chromium and 50% of maternal cobalt). Physicians and women of child-bearing age should be aware of this potential effect when considering the use of MOM-bearing implants.

Background: Elevated cobalt and chromium ion concentrations have been associated with the use of metal-on-metal bearings in hip arthroplasty. The use of a differential hardness bearing may reduce metal particle release. The aim of our study was to compare circulating cobalt (Co) and chromium (Cr) ion levels between patients treated with a standard all 'as-cast' heat treated bearing and a differential hardness bearing., Materials and Methods: One hundred and thirty-two patients implanted with unilateral hip resurfacing arthroplasties and having had blood metal ion studies performed between one and six years after surgery were retrospectively selected. There were 73 patients in the standard all 'as cast' heat treated bearing group (group 1) and 59 in the differential hardness bearing group (group 2)., Results: Clinical and quality of life scores were comparable between groups. The median Co in group 1 was 1.01 µg/L and 1.23 µg/L in group 2 (p = 0.0566). The median Cr in group 1 was 1.60 µg/L and 1.34 µg/L in group 2 (p = 0.0505)., Conclusion: Compared with conventional heat-treated CoCr bearings, differential hardness metal-on metal bearings do not confirm in vivo the hopes of a substantial reduction in circulating metal ions concentrations suggested by in vitro wear studies.

Background: The benefits of using thin acetabular components for hip resurfacing have been shown in terms of bone conservation, but there currently are little data available in the literature addressing the mid-term clinical results of these devices., Questions/purposes: We aimed to determine whether thinner acetabular components altered mid-term postoperative clinical scores, complication rates, survivorship, radiographic appearance, and metal ion levels., Methods: Two hundred eighty-one patients with unilateral disease received a 5-mm thick acetabular shell and 223 received a 3.5-mm shell. The femoral component implanted in both groups was identical. We compared clinical scores, complication rates, survivorship, radiographic results, and ion levels between these two groups., Results: UCLA hip scores were similar (pain, p = 0.0976; walking, p = 0.9571; function, p = 0.9316; activity, p = 0.2085). Complications were higher in the 5-mm group (6.4% versus 1.8%, p = 0.0431). Both groups were similar regarding survivorship (p = 0.3181), cup radiolucency at 5 years (p = 0.107), and metal ion levels (cobalt p = 0.404, chromium p = 0.250)., Conclusions: With comparable mid-term clinical results, there is no tangible reason to abstain from using the 3.5-mm acetabular component., Level of Evidence: Level III, retrospective comparative study. See the Guidelines for Authors for a complete description of levels of evidence.

Due to the well-documented problems surrounding metal-on-metal bearings, the use of hip resurfacing has declined. Since the potential benefits of hip resurfacing remain desirable, it may be beneficial to investigate the long-term outcome of hip resurfacings using metal-on-polyethylene in the 1980's. We report the long-term survivorship and modes of failure of a cementless metal-on-polyethylene resurfacing (n = 178) with different porous ingrowth surfaces. While acetabular loosening was absent, a high incidence of femoral failures (femoral loosening = 18.1%, osteolytic neck fracture = 21%) occurred despite using the same ingrowth surface for both components. Ongoing developments using the lessons learned from these previous generation components and utilizing modern low wear materials, e.g., cross-linked polyethylene, may lead to improved implants for future hip resurfacings., (© 2014 Elsevier Inc. All rights reserved.)

There have been increasing concerns regarding adverse local tissue reactions (ALTR) following metal-on-metal (MOM) hip arthroplasties. This study examined wear rates in retrievals of one design of MOM resurfacing arthroplasty, and assessed the differences in wear between those with and without ALTR. Wear measurements were made on 39 MOM resurfacing components (30 femoral, 9 acetabular) which were at least 2years in vivo. Seven hips (6 patients; 4 acetabular components, 7 femoral components) were identified to have ALTR. Acetabular component abduction and anteversion angles were determined using EBRA, and the contact-patch-to-rim (CPR) distance was calculated. The ALTR group had higher linear femoral and acetabular wear rates, acetabular anteversion and abduction angles, lower CPR, and longer time to revision. Given the increased risk for ALTR associated with acetabular component malpositioning, patients with malpositioned acetabular components may require closer clinical follow-up and monitoring., (Copyright © 2014 Elsevier Inc. All rights reserved.)