The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 92, Issue 7

Scientific Articles | July 07, 2010

Functional Results of Isolated Femoral Revision of Hip Resurfacing Arthroplasty

Rob E. Gilbert, MRCS¹; Graham Cheung, MRCS¹; Andrew D. Carrothers, MRCS¹; Carl Meyer, MRCS¹; James B. Richardson, FRCS¹

¹ Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, Shropshire SY10 7AG, United Kingdom. E-mail address for R.E. Gilbert: drrobgilbert@aol.com

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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 Smith and Nephew. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, Shropshire, United Kingdom

J Bone Joint Surg Am, 2010 Jul 07;92(7):1600-1604. doi: 10.2106/JBJS.I.00698

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Abstract

Background:

Conversion of a failed femoral resurfacing component is reportedly a straightforward procedure; however, little has been published regarding the functional results following revision. Our primary aim was to compare the functional results for a group of patients who had had isolated femoral component revision after a failed hip resurfacing with those for a group of patients with a surviving hip resurfacing. Our secondary aim was to identify whether the mode of failure affects functional outcome.

Methods:

Between 1997 and 2002, data were prospectively collected on 5000 Birmingham Hip Resurfacing procedures. One hundred and seventy-seven hips were revised, and, of those, seventy-six had an isolated femoral component revision. We reviewed the modes of failure and the post-revision clinical outcomes for this subgroup (the revised implant group) and compared the results with those for the patients who had a surviving hip resurfacing implant (the surviving implant group).

Results:

The median Harris and Merle d'Aubigné hip scores were significantly better in the surviving implant group than in the revised implant group (median Harris score, 96 compared with 82 [p < 0.001]; median Merle d'Aubigné score, 17 compared with 14 [p < 0.001]). When we analyzed outcomes following revision, we found that the mode of failure affected outcome. Patient satisfaction and clinical outcomes were worse following revision because of femoral component loosening in comparison with revision because of femoral neck fracture or revision because of femoral head collapse or osteonecrosis. In these three subgroups, the median Harris hip scores were 66, 87, and 92, respectively, and the median Merle d'Aubigné scores were 10, 14, and 15, respectively. Six of fifteen patients in the femoral loosening group believed that they were worse or much worse after the revision than they had been before the primary procedure, compared with four of twenty-five patients in the femoral neck fracture group and two of twenty-two patients in the femoral head collapse or osteonecrosis group. Four patients (four hips) experienced complications as a consequence of revision surgery (three deep infections and one case of loosening of an uncemented femoral stem).

Conclusions:

The functional results for patients who had revision of the femoral component of a current-generation metal-on-metal resurfacing arthroplasty were worse than those for patients with a surviving hip resurfacing. Patients who had revision because of femoral component loosening had worse outcomes than those who had revision because of femoral neck fracture or femoral head collapse or osteonecrosis.

Level of Evidence:

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

While conversion of a failed femoral resurfacing component is reportedly a straightforward procedure¹, little has been published regarding the functional results following revision to a total hip replacement. Following hip resurfacing arthroplasty, some of the femoral head and all of the femoral neck are preserved. This bone is subsequently loaded, thereby preventing stress-shielding and thus preserving proximal femoral bone stock². Should a femoral-side failure occur, this preserved proximal femoral bone stock is advantageous as the femoral neck can be osteotomized and a conventional stemmed femoral prosthesis with a large femoral head to match the retained acetabular component can be inserted. The technical simplicity of the revision procedure can be claimed to be an advantage³, but the functional results following revision surgery have yet to be established.

The primary objective of the present study was to compare the functional results for a group of patients managed with isolated femoral component revision after a failed hip resurfacing (revised implant group) with those for a group of patients who had a surviving hip resurfacing (surviving implant group). The secondary objective was to identify if the mode of failure affects functional outcome.

Materials and Methods

Between July 1997 and November 2002, the Oswestry Outcome Centre independently and prospectively collected data on 5000 Birmingham Hip Resurfacing procedures (Smith and Nephew Orthopaedics, Bromsgrove, United Kingdom) performed by 141 surgeons at eighty-four hospitals in forty-four countries. Of the original 5000 hip resurfacings, 3346 (67%) were performed in male patients and 1654 (33%) were performed in female patients (male:female ratio, 2:1). The mean age at the time of the operation was 52.5 years (range, thirteen to eighty-seven years); the mean age (and standard deviation) was 53.2 ± 9.5 years for male patients and 51.1 ± 10.5 years for female patients. At the time of the most recent follow-up, 4529 hip resurfacings remained in situ, 137 hips had been in patients who had died, 156 hips had been lost to follow-up, one hip resurfacing had been removed at the time of a hindquarter amputation following road traffic trauma, and 177 hips had been revised. Prior to surgery, all patients consented to participate in the present study and institutional review board approval was obtained. Questionnaires comprising the Harris⁴ and Merle d'Aubigné hip scores⁵ and patient satisfaction scores were mailed to all patients six months after surgery and annually thereafter for the first five years; additional questionnaires were completed at seven and ten years. If a questionnaire was not returned within six weeks after the initial postage, another questionnaire was sent. The assessment of patient satisfaction required the patients to rank their satisfaction, on a scale from 0 to 4, as extremely pleased (4), pleased (3), no different (2), worse than before (1), or much worse than before (0). A modification of the Harris hip score was used in order to allow patients to self-score and thereby eliminate surgeon bias. Clinical and radiographic examinations were not performed as part of this study. When a revision had taken place, the operating surgeon returned a pro forma indicating the mode of failure, the date of revision surgery, the revision implants used, any complications encountered, and any other comments relating to the revision procedure. Patients were contacted with a questionnaire following the revision surgery as was done following the primary procedure.

The scores for patients with isolated femoral component failure (the revised implant group) were compared with the scores for patients who had the primary hip resurfacing in situ (the surviving implant group). We then divided the revised implant group on the basis of the mode of failure as documented by the revising surgeon. The function following revision surgery was then compared among the three common modes of failure.

Statistical Analysis

Nonparametric data (i.e., hip scores) were analyzed with use of the Mann Whitney U test for nonmatched data. For normally distributed parametric data such as time to revision, Student t tests were used. The level of significance was set at p < 0.05.

Source of Funding

External funding was provided for data collection by Smith and Nephew Orthopaedics, Bromsgrove, United Kingdom. Funds were used for secretarial support and supplies.

Results

One hundred and seventy-seven hips required revision surgery. Seventy-six revision procedures involved isolated femoral component revision (with the original acetabular component being left in situ); of those, thirty-one were performed because of a fracture of the femoral neck, twenty-six were performed because of femoral head collapse or osteonecrosis, eighteen were performed because of femoral component loosening, and one was performed because of dislocation.

At the time of revision surgery, thirty-one cemented and thirty-two uncemented stemmed femoral prostheses were used; the remaining thirteen femoral revision prostheses were classified as unknown because incomplete data were returned by the revising surgeon. One patient had the hip resurfacing femoral component exchanged and recemented. Sixty-nine patients received a Birmingham Hip Resurfacing modular metal head (Smith and Nephew Orthopaedics), two received a custom-made Exeter head (Stryker, Newbury, United Kingdom), and two received a Metasul head (Zimmer, Swindon, United Kingdom); for the remaining three patients, the type of implant was unknown. The Exeter and Metasul heads matched the diameter and clearance of the resurfacing femoral component being replaced.

Sixty-three patients (mean age, 53.7 ± 10.2 years) completed questionnaires after a mean duration of follow-up of 3.8 ± 2.2 years. The median post-revision Harris hip score was 82 (interquartile range, 63 to 93.5) and the median Merle d'Aubigné hip score was 14 (interquartile range, 10 to 16).

All patients with the 4529 surviving resurfacings returned their follow-up questionnaires. Those patients had a mean age of 52.6 ± 9.8 years, a median Harris hip score of 96 (interquartile range, 88 to 100), and a median Merle d'Aubigné hip score of 17 (interquartile range, 15 to 18) after a mean of 7.1 ± 1.7 years. These hip scores were significantly better than those for the group with femoral revision (p < 0.001 for the Harris hip score and p < 0.001 for the Merle d'Aubigné hip score). The median patient satisfaction score was significantly better in the surviving implant group than in the revised implant group (4 compared with 3; p < 0.001).

The duration of follow-up was significantly longer in the surviving implant group than in the revised implant group (7.1 compared with 3.7 years; p < 0.001); however, this finding should not affect the comparison of hip scores between the groups as the scores remained relatively constant over time in the surviving implant group after six months postoperatively.

When we analyzed functional outcomes for the three common modes of failure, we found that patients with femoral loosening had significantly lower hip scores after revision than did patients with femoral head collapse or osteonecrosis (p = 0.02) (Table I). The group with femoral loosening also had lower scores than did the group with femoral neck fracture, although this difference was not significant (p = 0.08). The median Harris hip score was 66 for the group with femoral loosening, 87 for the group with a femoral neck fracture, and 92 for the group with femoral head collapse or osteonecrosis. The median Merle d'Aubigné score was 10 for the group with femoral loosening, 14 for the group with femoral neck fracture (p = 0.06), and 15 for the group with femoral head collapse or osteonecrosis (p = 0.014).

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TABLE I Demographic Data According to Mode of Failure

	Femoral Neck Fracture	Femoral Loosening	Femoral Head Collapse/Osteonecrosis	Dislocation
Number of patients	31	18	26	1
Age*(yr)	54	49	54	40
Male:female ratio	2:1	1.25:1	2.6:1	0:1
Time to failure*(yr)	1.6	3.0	4.0	0.5
Time to follow-up after revision surgery*(yr)	4.6	3.7	2.7	6.3
Harris hip score†	87	66	92	71
Merle d'Aubigné hip score†	14	10	15	12
Patient satisfaction score†	3	2	4	3
Repeat revision (no. of patients)	2	0	2	0

*The values are given as the mean.
†The values are given as the median.

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TABLE I Demographic Data According to Mode of Failure

	Femoral Neck Fracture	Femoral Loosening	Femoral Head Collapse/Osteonecrosis	Dislocation
Number of patients	31	18	26	1
Age*(yr)	54	49	54	40
Male:female ratio	2:1	1.25:1	2.6:1	0:1
Time to failure*(yr)	1.6	3.0	4.0	0.5
Time to follow-up after revision surgery*(yr)	4.6	3.7	2.7	6.3
Harris hip score†	87	66	92	71
Merle d'Aubigné hip score†	14	10	15	12
Patient satisfaction score†	3	2	4	3
Repeat revision (no. of patients)	2	0	2	0

*The values are given as the mean.
†The values are given as the median.

In an analysis of the separate components of the Merle d'Aubigné hip score (pain, mobility, and movement), we found that the group with loosening had lower scores for all three categories in comparison with the group with a femoral neck fracture and the group with femoral head collapse or osteonecrosis (Table II). The median scores for mobility and movement were significantly lower for the group with loosening than for the group with head collapse or osteonecrosis (2 compared with 5 [p = 0.04] and 5 compared with 6 [p = 0.047], respectively).

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TABLE II Components of Merle d'Aubigné Hip Score Following Revision of Femoral Component According to Mode of Failure

	Merle d'Aubigné Hip Score*(points)
Mode of Failure	Median	Pain	Mobility	Movement
Femoral neck fracture (n = 25)	14	5	3	6
Femoral loosening (n = 15)	10	3	2	5
Femoral head collapse/osteonecrosis (n = 22)	15	5	5	6

*The group with femoral loosening had significantly lower scores for mobility (p = 0.04) and movement (p = 0.047) in comparison with the group with femoral head collapse or osteonecrosis.

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TABLE II Components of Merle d'Aubigné Hip Score Following Revision of Femoral Component According to Mode of Failure

	Merle d'Aubigné Hip Score*(points)
Mode of Failure	Median	Pain	Mobility	Movement
Femoral neck fracture (n = 25)	14	5	3	6
Femoral loosening (n = 15)	10	3	2	5
Femoral head collapse/osteonecrosis (n = 22)	15	5	5	6

*The group with femoral loosening had significantly lower scores for mobility (p = 0.04) and movement (p = 0.047) in comparison with the group with femoral head collapse or osteonecrosis.

The level of patient satisfaction was also significantly lower in the group with femoral loosening than in the group with femoral head collapse or osteonecrosis (p < 0.001) and the group with femoral neck fracture (p = 0.011) (Table III). Six of fifteen patients in the femoral loosening group believed that they were worse or much worse after the revision than they had been before the primary procedure, compared with four of twenty-five patients in the femoral neck fracture group and two of twenty-two patients in the femoral head collapse/osteonecrosis group.

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TABLE III Patient Satisfaction Following Revision of Femoral Component According to Mode of Failure

Mode of Failure	Median Satisfaction Score*†(points)	Extremely Pleased	Pleased	No Different	Worse	Much Worse
Femoral neck fracture (n = 25)	3	12 (48%)	7 (28%)	2 (8%)	1 (4%)	3 (12%)
Femoral loosening (n = 15)	2	1 (7%)	5 (33%)	3 (20%)	3 (20%)	3 (20%)
Femoral head collapse/osteonecrosis (n = 22)	4	15 (68%)	5 (23%)	0 (0%)	1 (4.5%)	1 (4.5%)

*Possible range, 0 to 4 points.
†The median patient satisfaction score was significantly lower in the group with femoral loosening than in the group with femoral head collapse or osteonecrosis (p < 0.001) and the group with femoral neck fracture (p = 0.011).

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TABLE III Patient Satisfaction Following Revision of Femoral Component According to Mode of Failure

Mode of Failure	Median Satisfaction Score*†(points)	Extremely Pleased	Pleased	No Different	Worse	Much Worse
Femoral neck fracture (n = 25)	3	12 (48%)	7 (28%)	2 (8%)	1 (4%)	3 (12%)
Femoral loosening (n = 15)	2	1 (7%)	5 (33%)	3 (20%)	3 (20%)	3 (20%)
Femoral head collapse/osteonecrosis (n = 22)	4	15 (68%)	5 (23%)	0 (0%)	1 (4.5%)	1 (4.5%)

Complications

Following revision surgery, four patients (four hips) experienced complications. Three hips developed a deep infection (each approximately two years following the primary surgery). All underwent two-stage debridement and removal of the prosthesis, followed by the insertion of a revision prosthesis at a later date once the infection had been controlled. One hip subsequently developed another infection and required additional debridement. One hip developed loosening of an uncemented femoral stem and was revised to a larger uncemented prosthesis, with the acetabular component remaining in situ. Two complications (one deep infection and one case of stem loosening) occurred in the group with a femoral neck fracture, and two (both deep infections) occurred in the group with femoral head collapse or osteonecrosis.

Discussion

It has been stated that revision of the femoral component following hip resurfacing yields results similar to those of primary total hip replacement; however, there is little in the literature to corroborate this claim^1,3. Our results showed a significant decline in function following revision of the femoral component of total hip resurfacing when compared with surviving hip resurfacings, regardless of the mode of failure. This finding comes as no surprise as a second surgical insult to the soft tissues around the hip can cause detriment to function. When we analyzed functional outcomes for the various causes of failure, we found that patients with femoral loosening had significantly lower hip scores after revision surgery than did those with femoral neck fracture and those with femoral head collapse or osteonecrosis (p = 0.012). When we analyzed the components of the Merle d'Aubigné hip score, we found that hips that were revised because of femoral loosening had worse scores for pain, mobility, and movement in comparison with those that were revised because of femoral neck fracture and those that were revised because of femoral head collapse or osteonecrosis. We hypothesize that femoral loosening could be a biological event^6-8 whereas femoral neck fractures and head collapse or osteonecrosis are mechanical causes of failure⁸. If failure is due to a mechanical or structural problem, once the femoral head and neck have been osteotomized and a stemmed prosthesis has been inserted, removing the cause of failure, the patient will assume the function of a conventional hip replacement. If loosening is due to a biological response, such as macrophage activation⁹ resulting from metal wear or metal ion hypersensitivity, the cause of failure may remain following a revision total hip replacement with retention of the metal-on-metal bearing. This may explain the continued poorer hip function following revision in this cohort. If a biological failure mechanism is found, we believe that consideration must be given to revising both components to an alternative bearing combination.

Two other studies have been performed in an attempt to analyze function after isolated femoral component revision following failed hip resurfacing^1,3. Both studies involved small numbers of patients. Ball et al.³ reported on a series of twenty-one hips that had failure of the femoral component after hip resurfacing; however, only eighteen hips retained the acetabular component. The authors concluded that conversion of a hip resurfacing with a femoral-sided failure to a primary total hip arthroplasty appears to be comparable with primary total hip arthroplasty in terms of surgical effort, safety, and early clinical outcomes. McGrath et al.¹ reported on a series of thirty-nine hips that were treated with revision hemiarthroplasty or total hip resurfacing. Only sixteen hips had conversion of the femoral component following a total hip resurfacing, with the cup being left intact. The authors concluded that, when a resurfacing procedure fails, conversion to a conventional total hip replacement has early clinical and radiographic outcomes similar to those of primary conventional total hip replacement. Because of the small numbers available for study (due to the relative rarity of this complication) and the mixture of revision procedures, firm conclusions cannot be extrapolated from those two studies.

The present study had some limitations. First, the information regarding the details of the revision procedure (i.e., the date of revision, the mode of failure, and the revision components used) was provided by the revising surgeon, in a fashion similar to that of joint registries. For example, for thirteen of the seventy-six revision procedures, it is unknown whether the stem was cemented or uncemented. Second, 156 patients (3.12%) from a cohort of 5000 patients were lost to follow-up and thirteen of the seventy-six patients who had a revision were lost to follow-up or did not have complete follow-up data. The physical function and pain scores for these thirteen patients are unknown, and the present study examined the results of the other sixty-three revisions. We believe that the young age of our study population (mean, 52.5 years) and the wide geographical distribution of the patients (across forty-four countries) contributed to the loss-to-follow-up rate. Other limitations were the lack of implant retrieval analysis and the relatively short duration of follow-up in the revision cohort (mean, 3.8 years).

The present study also lacked any radiographic follow-up. This was because our primary aim was to evaluate postoperative hip function following hip resurfacing arthroplasty. Moreover, radiographic follow-up may not be a good predictor of survival or function of a hip prosthesis. This has been illustrated by studies of the Trent arthroplasty register. With use of that database, Allami et al. observed that, at five years of follow-up, twenty-five patients (5.2%) had gross radiographic features of failure¹⁰. However, at ten years of follow-up, only five of the twenty-five patients had had revision of the prosthesis. We therefore believe that radiographic analysis would not have added substantially to the present study.

In conclusion, the present prospective, independent, multicenter study shows that while the Birmingham Hip Resurfacing continued to function well after a mean duration of follow-up of seven years, the function declined following femoral component revision surgery. The reduction in function following revision surgery was dependent on the mode of failure, and patients should be counseled appropriately. Patients with aseptic loosening of the femoral component had worse function after revision of the femoral component to a total hip replacement than did patients in whom a femoral neck fracture or osteonecrosis was the mechanism of failure. We speculate that aseptic loosening as a mode of failure may be due to a biological cause that stems from the metal-on-metal articulation. Consideration should therefore be given to revising both the femoral and acetabular components in the presence of femoral component loosening.

Acknowledgements

Note: The authors thank Mr. E. Robinson and the staff at the Oswestry Outcome Centre for all of their help and support.

References

McGrath MS; Marker DR; Seyler TM; Ulrich SD; Mont MA. Surface replacement is comparable to primary total hip arthroplasty. Clin Orthop Relat Res. 2009;467:94-100.[PubMed][CrossRef]

Kishida Y; Sugano N; Nishii T; Miki H; Yamaguchi K; Yoshikawa H. Preservation of the bone mineral density of the femur after surface replacement of the hip. J Bone Joint Surg Br. 2004;86:185-9.[PubMed][CrossRef]

Ball ST; Le Duff MJ; Amstutz HC. Early results of conversion of a failed femoral component in hip resurfacing arthroplasty. J Bone Joint Surg Am. 2007;89:735-41.[PubMed][CrossRef]

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737-55.[PubMed]

D'Aubigné RM; Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am. 1954;36:451-75.[PubMed]

Willert H-G; Buchhorn GH; Fayyazi A; Flury R; Windler M; Köster G; Lohmann CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am. 2005;87:28-36.[PubMed][CrossRef]

Park Y-S; Moon Y-W; Lim S-J; Yang J-M; Ahn G; Choi Y- L. Early osteolysis following second-generation metal-on-metal hip replacement. J Bone Joint Surg Am. 2005;87:1515-21.[PubMed][CrossRef]

Davies AP; Willert HG; Campbell PA; Learmonth ID; Case CP. An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements. J Bone Joint Surg Am. 2005;87:18-27.[PubMed][CrossRef]

Pandit H; Glyn-Jones S; McLardy-Smith P; Gundle R; Whitwell D; Gibbons CL; Ostlere S; Athanasou N; Gill HS; Murray DW. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90:847-51.[PubMed][CrossRef]

Allami MK; Fender D; Khaw FM; Sandher DR; Esler C; Harper WM; Gregg PJ. Outcome of Charnley total hip replacement across a single health region in England. The results at ten years from a regional arthroplasty register. J Bone Joint Surg Br. 2006;88:1293-8.[PubMed] [CrossRef]

Topics

femoral neck fractures ; femur ; head of femur ; hip joint ; repeat surgery ; osteonecrosis ; hip resurfacing arthroplasty

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Rob E. Gilbert, Graham Cheung, Andrew D. Carrothers, Carl Meyer, James B. Richardson; Functional Results of Isolated Femoral Revision of Hip Resurfacing Arthroplasty. The Journal of Bone & Joint Surgery. 2010 Jul;92(7):1600-1604.

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