Does the solution for young active patients with arthritic hip disease remain an “enigma”?

I stumbled across an article recently that was published in 2020 which stated, “The solution for the young patient with arthritic hip disease, and particularly for those patients with high functional demands, remains an enigma”¹.

For someone who has now been exposed to hip resurfacing arthroplasty (HRA) history and development for a year now, I found the use of the word “enigma” slightly baffling. The Cambridge Dictionary defines the meaning of ‘enigma’ as “something that is mysterious and seems impossible to understand completely”.

The article evaluates the existing literature in the field, and the current clinical evidence surrounding metal-on-metal HRA. It mentions a wide range of HRA benefits including;

· Reduced rates of dislocation compared to total hip arthroplasty² (THR)

· Mimicked anatomy and avoidance of activity restrictions³

· Easier revision options⁴

Naturally, the article does indeed discuss in detail the concerns regarding early failure rates of implant designs with poor radial clearance, and local adverse reactions to metallic wear debris which, as of 2019, led to $7.5 billion in settlements and verdicts⁵.

It is understandable that the poor results have been highlighted so much throughout literature, and within the media. However, by doing so, the good has been overlooked. The article itself even mentions the long-term clinical outcomes of both “BHR (447 hips) and Conserve Plus (962 hips) HRA implants with a 96.3% 10-year survival and 98.7% 10-year survival respectively”⁶.

These results alone show a clear solution to young active patients with high functional demands, and proves the solution is by no means a complete mystery.

Moving on three years since this article was published, we have seen technological advancements being made within the hip resurfacing industry, including, Ceramic-on-Ceramic (CoC) devices such as the H1 Ceramic Hip Resurfacing from Embody and MatOrtho’ s ReCerf ® Ceramic Hip Resurfacing, as well as JointMedica’s Polymotion® Hip Resurfacing System (PHR®) which is metal-on-vitamin-E crosslinked polyethylene. Due to the alternative materials, each device eliminates the health concerns caused by metal ions with metal-on-metal implants, allowing for a greater range of patients to be considered as a candidate for the procedure, including women.

With these three devices set to enter the market, have we now cracked the enigma code?

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References:

1. Clough, E J, and T M Clough. “Metal on metal hip resurfacing arthroplasty: Where are we now?.” Journal of orthopaedics vol. 23 123-127. 31 Dec. 2020, doi:10.1016/j.jor.2020.12.036

2. No authors listed . 2020. National Joint Registry for England and Wales.https://reports.njrcentre.org.uk (17th Annual Report).

3. Gerhardt D., Mors T.G.T., Hannink G., Van Susante J.L.C. Resurfacing hip arthroplasty better preserves a normal gait pattern at increasing walking speeds compared to total hip arthroplasty. Acta Orthop. 2019;90(3):231–236.

4. Blevins Jl, Shen T.S., Morgenstern R., DeNova T.A., Su E.P. Conversion of hip resurfacing with retention of monoblock acetabular shell using dual mobility components. J Arthroplasty. 2019;34:2037–2044

5. Turner T. Hip replacement lawsuits. Drugwatch. 2020 https://www.drugwatch.com/hip-replacement/lawsuits/

6. Girard J., Lons A., Ramdane N., Putman S. Hip resurfacing before 50 years of age: a prospective study of 979 hips with a mean follow-up of 5.1 years. Orthop Traumatol Surg Res. 2018;104(3):295–299