Recommendation None
Question 5: Does HR offer greater range of hip motion than THA?
Case clarification
On clinical examination, the patient has hip flexion of 100°, abduction 15°, adduction 5°, external rotation 15°, and internal rotation 5°. Since the patient would like to perform
Table 16.1 Summary of clinical outcomes Study Level of
evidence
Procedure No. of patients (hips)
Follow-up (months)
Mean clinical scores in points (range)
Conclusion
Pollard et al.
2006
III HR 54(54) 61 OHS(15.9 (12–42)
UCLA 8.4 (4–10)
Similar Oxford hip scores.
Resurfacing associated with higher activity levels
THA 54 (54) 80 OHS: 18.5 (12–41)
UCLA: 6.8 (3–10) Vail et al.
2006
III HR 52(57)) 36 HHS: 98
Activity subscore: 14
RHA associated with significantly higher HHS, ROM subscore, activity subscore, and function subscore
THA 84(93 36 HHS: 93
Activity score: 12.7 Vendittoli
et al.
2006
I HR 103 (hips) 12 WOMAC: 9.2
P-M: 16.7 UCLA: 7.1
Significantly higher activity level in HR group (p = 0.037)
THA 102 (hips) 12 WOMAC: 11.7,
P-M: 16.6, UCLA: 6.3 Girard et
al. 2008
II HR 69 P-M: 17 ± 0.35
WOMAC: 9.2 ± 15.1
Similar clinical scores
THA 79 P-M: 17 ± 0.4
WOMAC: 11.7 ± 11.4 Lavigne
et al.
2008
II HR 81 (81) 12 Overall activity: 17.9 points
WOMAC: 8.1 ± 13.1 points UCLA: 7.17 ± 2.8 points
Preoperative activity scores of the two groups were similar.
RHA associated with more frequent and more intense sports activities postoperatively
THA 71 (71) 12 Overall activity: 12.7 points
WOMAC: 9.8 ±10.9 points UCLA: 6.75 ± 1.71 points Mont et
al. 2009
III HR 54 (54) 39 HHS: 90 (50–100)
Satisfaction: 9.2 (2–10) Activity: 11.7 (0–32)
Midterm clinical outcomes and satisfaction scores similar. HR patients had higher activity scores, but also had higher preoperative activity scores
THA 54 (54) 39 HHS: 91 (62–100)
Satisfaction: 8.8 (0–10) Activity: 7 (0–20) Shrader
et al.
2009
II HR 7 (7) 3 LEAS: 12.6
HHS: 92.4 (better ROM scores with HR)
Better functional capability with HR. Greater improvements in hip extension and abduction moment after HR
THA 7 (7) 3 LEAS: 11.5
HHS: 90.4 Le Duff
et al.
2009
III HR 35(35) 88 UCLA pain score: 9 (7–10) No difference in clinical scores
THA 35(35) 96 UCLA pain score: 9 (4–10)
C H A P T E R 1 6 Hip Resurfacing vs. Metal-on-Metal Total Hip Arthroplasty
Study Level of evidence
Procedure No. of patients (hips)
Follow-up (months)
Mean clinical scores in points (range)
Conclusion
Fowble et al.
2009
II HR 50(50) 24 HHS: 97 (81–100)
UCLA: 8.2 (4–10) SF-12 Physical score 53.6(36.9–63) SF-12 Mental score 54.6 (26.7–61.7) Function: 46.4 (42–47) Pain: (Slight/Mild): 43%
HR patients had higher function (p = 0.007),SF-12 physical activity scores (p = 0.002) and UCLA activity scores (p = 0.0001), but also a higher incidence of slight or mild pain (p = 0.007)
THA 35 (44) 24 HHS: 96 (66–100)
UCLA: 5.9 (3–10) SF-12 Physical score 47 (15.2–57.6) SF-12 Mental score 52.5 (32.1–66.6) Function: 44.9 (36–47) Pain: (Slight/Mild): 20%
Lavigne et al.
2009
I HR 24(24) 12 WOMAC: 3 (0–12),
P-M: 17.9 (16–18), UCLA: 8 (5–10)
SF-36 Mental Score : 51.9 (45–60)
SF-36 Physical score: 55.2 (48–62)
Clinical scores are similar
THA 24(24) 12 WOMAC: 2.7 (0–16),
P-M: 18 (18), UCLA: 8.3 (6–10)
SF-36 Mental Score: 52.1 (36–65) SF-36 Physical score 53.3 (53–70) Garbuz
et al.
2009
I HR 48 12 WOMAC Pain: 91.51
Stiffness: 85.60 Function: 90.64 Global: 90.40 SF-36 Physical score 51.22 SF-36 Mental score 53.87
Clinical scores are similar. No difference in PAT-5D ambulation domain scores between two groups
THA 56 12 WOMAC Pain: 90
Stiffness: 83 Function: 91.07 Global: 90.18
SF-36 Physical Score 51.28 SF-36 Mental Score 55.13 Stulberg
et al.
2009
III HR 337 24 Total HHS (% of patients in
excellent category): 91.3 HHS Pain score: (% of patients having no pain): 80.6
Early advantages in HHS observed in HR group, but all differences faded by 24 months.
Ability to climb stair is the only subcomponent that is higher in HR group at 24 months
THA 266 24 Total HHS (% of patients in
excellent category): 91.1 HHS Pain score: (% of patients having no pain): 76.3 Table 16.1 (Continued)
(Continued)
and ≥40 mm). Fowble et al. compared 50 HR with 44 THA procedures at a minimum follow-up of 2 years, and found no significant difference in the postoperative range of motion between the two groups.12 However, the patients undergoing THA started with less ROM and had greater postoperative improvements in flexion, extension, and abduction.
Stulberg et al. compared Harris hip ROM score in 337 HR arthroplasties with 266 ceramic-on-ceramic THAs and found that although the THA group demonstrated greater flexion value, the resurfacing group showed slightly better results in abduction, adduction and internal rotation.41 Therefore, overall arc of motion at 24 months was similar between the two groups.
Li and colleagues measured ROM after HR and ceramic- on-ceramic THA in two groups of 21 patients, each with osteoarthritis secondary to hip dysplasia, and found sig- nificantly better ROM in the HR group (p < 0.05).44
In another study comparing clinical outcome of HR vs.
THA, the HR group exhibited significantly greater total ROM at 2 years (99° vs. 97°, p < 0.001).23 The authors believed that since the examiners were not blinded they may have been more reluctant to force extreme ROM in the THA group for fear of causing dislocation. It is important to note that a difference of 2° in ROM is clinically insignificant.
Lavigne et al. performed hip ROM measurements in 165 patients (LDH-THA, n = 55; THA, n = 50; and HR, n = 60) at minimum 1 year follow-up with a novel standardized method of hip ROM assessment.45 They found similar hip ROM in THA and HR. LDH-THA demonstrated a signifi- cant 20° increase in the total arc of hip ROM (p = 0.001).
Recommendations
• There is no difference in the postoperative ROM between HR and THA [overall quality: low]
martial arts after surgery, you explain him about expected improvement in range of motion (ROM) after HR vs. THA.
Relevance
ROM after hip arthroplasty is becoming an important issue, as patients present at a younger age and are willing to return to a high level of activity. The larger head diam- eter of HR is theoretically beneficial for improving hip ROM, although the larger neck diameter is unfavorable for the head to neck diameter ratio.
Current opinion
Current opinion suggests that the use of a larger head size in HR may provide greater clinical ROM compared to 28 mm THA.
Finding the evidence
• Cochrane Database with search term “hip resurfacing”
or “surface replacement arthroplasty”
• PubMed (www.ncbi.nlm.nih.gov/pubmed) sensitivity search using key words: “hip resurfacing or surface replace- ment arthroplasty” AND “range of motion”
• Embase with search term “hip resurfacing or surface replacement arthroplasty” AND “range of motion”
Quality of the evidence
Level III• 6 retrospective comparative studies
Findings
Six retrospective studies have compared ROM between HR and THA. LeDuff et al. reviewed 35 patients who had undergone bilateral surgery with HR on one side and THA on the other.40 They found no difference in any of the ROM measurements even after separating the cohort into two groups based on femoral head size of the THA (<40 mm
Study Level of evidence
Procedure No. of patients (hips)
Follow-up (months)
Mean clinical scores in points (range)
Conclusion
Zywiek et al.
2009
III HR 33 42 Weighted Activity Score: 10.0
(1.0–27.5) HHS: 91 (32–100)
Satisfaction Score: 9.1 (5–10) Pain Score: 1.3 (0–10)
Activity levels were significantly higher in the HR
group(p < 0.001)
THA 33 45 Weighted Activity Score: 5.3
(0–12.0) HHS: 90 (50–100)
Satisfaction Score: 9.1 (2–10) Pain Score: 1.2 (0–5) Table 16.1 (Continued)
C H A P T E R 1 6 Hip Resurfacing vs. Metal-on-Metal Total Hip Arthroplasty In a systematic review comparing HR vs. conventional THA, Marker et al. included three gait studies.48 The first one was a retrospective gender-matched study by Mont and colleagues. The study found at a mean 13-month follow-up that patients in the HR group walked faster than patients in either THA or control groups. However, there were no significant differences in hip abductor and extensor moments of patients in those two groups.
Lavigne and coworkers examined the distribution of energy generation and absorption in three groups of patients: HR, THA with large-diameter heads and THA with small-diameter heads. They found that patients who received HR and LDH-THA returned to more normal gait patterns than patients who had small-diameter femoral heads. Shimmin and associates compared HR and THA patients who had HHS of 100 to age-matched asympto- matic control patients. They reported no significant dif- ference in gait speed at either fast walking or jogging paces among any of the groups.
Lavigne et al. analysed gait speed and postural balance after HR and LDH-THA in a prospectively randomized double-blind study of 48 patients.25 A third group of 14 healthy subjects served as control. During normal and fast walking and for postural evaluation, both study groups showed similar postoperative results at 12 months. The time period needed for both groups of patients to reach the normal control subject’s value for each functional test was 3 months, except for the normal walking speed of the HR group, which reached the control value at 6 months postoperatively.
The postural balance study by Nantel and colleagues reported that THA had greater medial to lateral centers of pressure and mass displacement during dual stance when compared to HR (p < 0.05).49 The authors attributed the difference to better anatomical preservation, absence of femoral stem, and the larger bearing component in HR.
Recommendations
• Gait speed is greater and postural balance seems better after HR than after THA [overall quality: low]
• There is no difference in gait pattern and postural balance after HR and LDH-THA [overall quality: low]
Question 7: Is there any difference between