The Journal of Arthroplasty
Volume 25, Issue 4 , Pages 666-667, June 2010

In Reply:

Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia

Hospital for Special Surgery, New York, New York

Rothman Institute, Philadelphia, Pennsylvania

published online 03 May 2010.

Article Outline

 

We wish to thank Dr Brooks for his letter with reference to our Editorial “Metal on Metal: Is It Worth the Risk?” [1]. We agree with Dr Brooks that there are “unanswered” questions about this bearing couple. Dr Brooks agrees that it is hard to identify clinical advantages for the use of metal-on-metal bearings in total hip arthroplasty.

The issue of resurfacing was not considered specifically in the Editorial. However, Dr Brooks states that the potential disadvantages of metal-on-metal articulation are outweighed by benefits seen from resurfacing. These benefits are difficult to identify when the resurfacing implants were the worst performing implants in both the Australian and the English Registry 2, 3. Dr Brooks highlights this in his letter. Furthermore, if he had elected to compare the results of resurfacing to cemented or hybrid implants, the worse outcome of resurfacing would be even more obvious.

Resurfacing carries the same potential risks of metal-on-metal bearings and does not improve survivorship. With conflicting reports in the literature, there is little evidence that resurfacing restores hip anatomy any better than a primary total hip arthroplasty 4, 5. There are major concerns with pain around resurfacing hips. In a recent article by Beaulé et al, an 18% incidence of significant groin pain in young patients was reported [6]. This incidence is 4 to 50 times the groin pain rates reported in total hip arthroplasty.

Another important issue is revision surgeries after resurfacing. It is generally believed revising a resurfacing to a primary total hip arthroplasty is a relatively straight forward procedure. However, the Australian Registry data would not support this hypothesis. In fact, the rerevision rate 5 years after revision of a resurfacing to a primary total hip arthroplasty is approximately 11%. This is a significantly worse outcome than a primary total hip arthroplasty, and patients must be counseled that revision of a failed resurfacing is not an easy or predictable procedure.

Again the authors maintain the position that metal-on-metal bearings should be used “with great caution if at all.” Resurfacing does not avoid the issues related to metal-on-metal bearings and their use introduces a new series of complications while showing high revision rates in the hands of the general orthopedic surgeon.

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References 

  1. Crawford RW, Ranawat CS, Rothman RH. Metal on metal: is it worth the risk?. J Arthroplast. 2010;25:
  2. AOA Australian Orthopaedic Association National Joint Replacement Registry annual report. Adelaide: AOA; 2008;
  3. The National Joint Registry 5th annual report. Hemel Hempstead: National Joint Registry for England and Wales; 2009;
  4. Girard J, Lavigne M, Vendittoli PA, et al. Biomechanical reconstruction of the hip: a randomised study comparing total hip resurfacing and total hip arthroplasty. J Bone Joint Surf Br. 2006;88:721
  5. Loughead JM, Chesney D, Holland JP, et al. Comparison of offset in Birmingham hip resurfacing and hybrid total hip arthroplasty. J Bone Joint Surg Br. 2005;87:163
  6. Bin Nasser A, Beaulé PE, O'Neill M, et al. Incidence of groin pain after metal-on-metal resurfacing. Clin Orthop Relat Res. 2010;468:392

PII: S0883-5403(10)00219-6

doi:10.1016/j.arth.2010.03.024

The Journal of Arthroplasty
Volume 25, Issue 4 , Pages 666-667, June 2010

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