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Early Results of Conversion of a Failed Femoral Component in Hip Resurfacing Arthroplasty
Scott T. Ball, MD1; Michel J. Le Duff, MA2; Harlan C. Amstutz, MD2
1 Department of Orthopaedics, University of California, San Diego, 9500 Gilman Drive, Department 630, La Jolla, CA 92093
2 Joint Replacement Institute, Orthopaedic Hospital, 2400 South Flower Street, Los Angeles, CA 90007. E-mail address for H.C. Amstutz: hamstutz@laoh.ucla.edu
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Wright Medical Technology. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Wright Medical Technology). Also, a commercial entity (Wright Medical Technology) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Joint Replacement Institute at Orthopaedic Hospital, Los Angeles, California

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Apr 01;89(4):735-741. doi: 10.2106/JBJS.F.00708
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Background: A theoretical advantage of resurfacing arthroplasty of the hip is that a failed femoral component can be safely and successfully revised to a total hip arthroplasty. To our knowledge, this advantage has not been demonstrated to date.

Methods: Twenty-one metal-on-metal resurfacing arthroplasties in twenty patients with an average age of 50.2 years were converted to a conventional stemmed total hip arthroplasty because of femoral component failure. In eighteen hips, the acetabular component was retained, and in three hips both components were revised. The results in the resurfacing conversion group were compared with those in a group of fifty-eight patients who had undergone sixty-four primary total hip arthroplasties that had been performed during the same time-period by the same surgeon. Clinical evaluations (the Harris hip score, the University of California at Los Angeles pain, walking, and activity scores and the Short Form-12 score) and radiographic evaluations were performed. The average duration of follow-up was forty-six months for the conversion arthroplasty group and fifty-seven months for the primary conventional total hip arthroplasty group.

Results: There was no significant difference between the conversion arthroplasty group and the conventional arthroplasty group with regard to operative time, blood loss, or complication rates. At the time of the most recent follow-up, with the numbers studied, there were no significant differences between the two groups with regard to the mean Harris hip score; the University of California at Los Angeles pain, walking, and activity score; or the SF-12 score. As assessed radiographically, the quality of component fixation and the alignment of the reconstruction were equivalent between the two groups. There had been no instances of aseptic loosening of the femoral or the acetabular component in either group, and there had been no dislocations after conversion of a resurfacing arthroplasty.

Conclusions: Conversion of a hip resurfacing with a femoral-side failure to a total hip arthroplasty appears to be comparable with primary total hip arthroplasty in terms of surgical effort, safety, and early clinical outcomes.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Shearwood J. McClelland, MD, MPH, FACS
    Posted on April 30, 2007
    Revising Femoral-Side Surface Replacement Failures
    Harlem Hospital Center, 506 Lenox Avenue, New York, NY 10037

    To The Editor:

    While I read with interest the authors’ encouraging results in revising femoral-side failures of current-generation hip surface replacement arthroplasties, I was surprised that their well-researched bibliography, with references dating back into the 1970s, failed to note a pertinent article on this subject that I and my co-authors published over twenty years ago.(1) That paper presented two-to-three year follow-up observations of three femoral-side revisions of first-generation resurfacing failures using an outer-diameter matched, press-fit bipolar prosthesis to articulate with the retained acetabular cup. These novel revisions had “created” the theretofore unreported surgical entity of a true bipolar total hip arthoplasty, with two distinct, but biomechanically linked, metal-on-polyethylene articulating interfaces. Fluoroscopic evaluations of these three hips (and one set of x-rays included in the article) strongly suggested the preservation and predominance of inner- bearing motion which, we inferred, might be beneficial in enhancing the longevity of the retained acetabular components. Unfortunately, these procedures were performed in a highly mobile military population, and no follow-up beyond that noted in the article was possible. Moreover, concerns about the subsequent longevity of the relatively thin, non-metal backed acetabular shells undoubtedly led many surgeons to opt for revising such failures to a conventional total hip replacement.

    The current generation of hip resurfacing implants, with its use of metal-on-metal articulations and cementless technology, has significantly minimized concerns about frictional torque and the wear debris from larger articulating interfaces as potential causes of premature failure. However, despite these advances, isolated femoral-side failures of these procedures do still occur; and as the authors have shown, revision using a head diameter matched unipolar stem appears to be a technically feasible and highly satisfactory surgical solution. However, should the currently unresolved issue of accumulated metal ion release from these implants rise to a level of concern that leads to the reconsideration of a technology- enhanced metal-on-plastic resurfacing option, the concept of a bipolar conversion for those femoral-side failures may be worth a more formalized revisiting and assessment.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .


    1. McClelland SJ, Godfery JD, Benton PC, and Slemmons, BK. Revision of Failed Hip Surface Replacement Arthroplasties With A Bipolar Prosthesis. Three Case Reports with Two-to-Three Year Follow-Up Observations. Clin Orthop Relat Res. 1986; 208: 243-248.

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