Updated 10/2/2014

Peter Brooks MD, FRCS(C)
www.clevelandclinic.org

216-444-4284
brooksp@ccf.org

I have been performing hip resurfacing at Cleveland Clinic
using the Birmingham Hip Resurfacing System (BHR) since
2006, shortly after it became the first resurfacing device
to be approved by the FDA. Two of my partners perform BHR as
well. We also perform total hip replacement (THR).

I would agree with Dr Gross, “The Durability of Hip
Resurfacing” on this site

in his excellent rebuttal to an ongoing series of dubious
studies and apples-to-oranges comparisons in the orthopedic
literature, mass media, national registries, and personal
series. I have been very pleased with the outstanding
results of hip resurfacing when done in the right patient,
using a properly designed device, with well placed implants.

At this time, I have implanted almost 1500 BHR devices. I
would like to share our results, as published recently in
the Journal of Bone and Joint Surgery, the premier medical
journal of our field. We looked at patient age, gender,
activity level, general health, complications, revisions,
and functional outcomes, and compared these with our
standard stemmed total hip replacements (THR).

We analyzed 678 BHR resurfacing patients with a 2 to 6-year
follow-up, and compared these with 1221 THR patients in the
same time period. The BHR resurfacing patients had an
average age of 54, and 71% were male. In contrast, the THR
patients had an average age of 63, and 45% were male.

The BHR resurfacing patients had better outcomes than the
THR group: a shorter hospitalization, half the rate of
readmission to hospital after discharge, and one-tenth the
rate of re-operations (for such things as infections,
dislocations, loosening, fracture etc) compared to THR. In
addition, the BHR patients had higher functional scores at
follow-up than our THR’s, a difference which persisted even
after statistical correction for age, gender and health
status.

Looking at all the 1500 or so resurfacings that I have done,
there have been remarkably few complications. One patient
had a femoral neck fracture 6 years ago, and none since
then. I have had no dislocations, no femoral loosening, one
loose socket, and one infection. These complications are
very infrequent when compared to reported results for
traditional THR. One female patient fell down an escalator
and broke her pelvis eventually needing a THR, and one
patient had late head collapse (AVN). We have not seen any
metal ion-related complications such as pseudotumors.
Overall, the BHR in our center has a greater than 99%
success rate at up to 6 years follow-up. These kinds of
results have already been seen by experienced hip surgeons
in other centers around the world, where the BHR has been
available for 15 years.

I also agree with Dr Gross about the learning curve and
level of difficulty involved in hip resurfacing. Step one of
a traditional THR is cutting off the top 3-4 inches of the
upper femur. This allows a wide surgical view of socket
placement, where accurate positioning is the key to
longevity of the implant. In resurfacing, however, the head
and neck of the femur are not removed, so adequate exposure
of the hip socket is difficult. A common place analogy would
be trying to repair the engine of your car, but you’re not
allowed to raise the hood more than a couple of inches. To
accomplish this requires a lot of experience. In addition
there is the challenge of getting the head (femoral)
component in the correct position which is also an
additional level of complexity when compared to a
traditional THR. In my experience it takes most surgeons 100
procedures to get consistent accuracy of placement of the
implants for hip resurfacing, and in some cases it may take
many more cases to become an expert surgeon.

Most orthopedic surgeons do not do any resurfacing at all.
That’s probably a good thing. Most surgeons don’t have the
large number of patients that are good candidates for hip
resurfacing to gain this level of surgical experience. And
most surgeons who attend training courses realize it’s not
for them. Some hip surgeons with large practices do not
recommend this procedure.

The only way to really be sure if you are a candidate for
resurfacing is to get an opinion from a surgeon who does
both traditional hip replacement and hip resurfacing. You
can find many of us on this website

, and almost all of us welcome e-mail inquiries, with X-rays
Basically,
anyone who does hip resurfacing does hip replacement as
well, but the reverse is not necessarily true. Hip
replacement and hip resurfacing do best in different types
of patients. They are not competing procedures, they are
complementary. The best candidates for resurfacing are
young, healthy people who have higher levels of activity.
These are some of the worst candidates for traditional total
hip replacement because they have the highest rates of
loosening and wear that require revision surgery.

The results reported for metal-on-metal total hip
replacement cannot be directly applied to metal-on-metal hip
resurfacing. The best resurfacing candidates are males under
65 with osteoarthritis. These patients do better with
resurfacing than with THR. Inferior results are seen in
women, hip dysplasia, and AVN.

You need to be the right patient, and have a properly placed
implant, using an implant with a good track record to
optimize your chances of getting a good long term result.

Disclosure: Dr Brooks collaborates with the medical device
industry in the development of better implants and
techniques for orthopedic patients. He is a consultant for
Stryker and for Smith and Nephew, the company which
manufactures the BHR. He receives no royalties for the BHR
or for any other implant. This post is personal to Dr Brooks
and does not necessarily reflect the opinions or positions
of the Cleveland Clinic. Cleveland Clinic does not endorse
any particular brand of medical device.