Metal-on-metal surface replacement: a triumph of hope over reason: affirms

Metal-on-metal hip resurfacing offers some potential for total hip arthroplasty (THA) in the young patient. However, short- and intermediate-term results of the currently available implants have failed to demonstrate advantage over conventional THA. The risks of femoral neck fracture or avascular necrosis have been disappointing early limitations of the procedure. The Australian Joint Registry reports a 5-year revision rate of all hip resurfacings of 3.8%, compared with conventional THAs at 2.8%, and a 9-year cumulative revision rate of 7.2% for hip resurfacings. Recent reports of femoral neck erosion and pseudotumors associated with resurfacing have raised concern about the survivorship of the procedure in some patients. Recently, the British Medicines and Healthcare Product Regulatory Agency issued an alert over adverse reactions associated with metal-on-metal THAs, with particular concern expressed about hip resurfacings. Acetabular bone stock may not be conserved when large-diameter femoral head components are used, depending on the surgical technique and implant design. In hip resurfacing, the minimum diameter femoral component avoids notching of the femoral neck; thus, larger diameter acetabular components may be necessary to accommodate the femoral component. Hip resurfacing is contraindicated in cases of avascular necrosis of the femoral head, especially with cysts >1 cm in diameter, with severe slipped capital femoral epiphysis, and in some posttraumatic arthroses; furthermore, the biomechanics of the resurfaced hip appear to be less reliably restored than with conventional THA. The hypothesis that resurfacing is a more conservative procedure than conventional THA remains unproven at this time. Given the documented intermediate failure rates of resurfacing, metal-on-polyethylene is the more successful implant choice.