Indications for Hip Resurfacing Arthroplasty

Indications for Hip Resurfacing Arthroplasty: A High-Yield Review for Orthopaedic Trainees

High-Yield Executive Summary

• Hip resurfacing arthroplasty (HRA) is primarily indicated for young, active patients with end-stage hip osteoarthritis who require bone preservation and high functional demand.
• Ideal candidates have good bone quality (typically males <60 years), minimal femoral head deformity, and no significant osteoporosis or avascular necrosis.
• HRA offers advantages in femoral bone stock preservation, lower dislocation rates, and easier revision compared to total hip arthroplasty (THA), but carries risks of metal ion release and femoral neck fracture.
• Contraindications include poor bone quality, severe femoral head collapse, renal insufficiency, and metal hypersensitivity.
• Surgical success hinges on precise component positioning, femoral neck preservation, and patient selection to minimize complications.

Clinical Fundamentals

Anatomy & Biomechanics:
The hip joint is a ball-and-socket synovial joint formed by the femoral head and acetabulum. Hip resurfacing preserves the femoral head and neck, maintaining native biomechanics and load transfer through the proximal femur. This preservation reduces stress shielding and maintains proximal femoral bone stock, critical for future revisions.

Epidemiology:
Osteoarthritis is the leading indication for hip arthroplasty. Younger, active patients (<60 years) with high functional demands increasingly seek durable solutions. HRA is less common than THA but remains relevant in select populations due to its bone-conserving nature.

Classification & Diagnosis

Classification Systems Impacting Management:

• Tönnis Grade for Osteoarthritis: Grades 2–3 (moderate to severe joint space narrowing, osteophytes) often indicate surgical intervention.
• Ficat and Arlet Classification for Avascular Necrosis (AVN): Early stages (I–II) may be amenable to HRA; advanced collapse (III–IV) contraindicates resurfacing.
• Bone Quality Assessment: DEXA scans or intraoperative assessment guide candidacy; poor bone density increases fracture risk.

Diagnostic Pearls:

• Preoperative imaging must include AP pelvis and lateral hip views; CT may assist in assessing femoral head sphericity and acetabular morphology.
• MRI is valuable for early AVN detection and cartilage assessment.
• Avoid HRA in patients with femoral head cysts >1 cm or significant head deformity.

Common Pitfalls:

• Underestimating femoral neck quality leads to intraoperative fractures.
• Overlooking metal hypersensitivity history can result in adverse local tissue reactions postoperatively.

The Decision-Making Algorithm

Non-Operative vs. Operative:

• Initiate with conservative management (NSAIDs, activity modification, physical therapy) in early osteoarthritis or low symptom burden.
• Proceed to surgery when pain and functional limitation persist despite optimized non-operative care.

Operative Indications for HRA:

• Age <60 years, male sex preferred due to lower femoral neck fracture risk.
• Good femoral head sphericity and bone quality.
• High activity level requiring durable, bone-preserving solution.
• Absence of contraindications (osteoporosis, renal failure, metal allergy).

Why HRA over THA?

• Bone preservation facilitates easier revision.
• Larger femoral head size reduces dislocation risk.
• Better restoration of native hip biomechanics and proprioception.

Implant Selection:

• Metal-on-metal bearings remain standard for HRA due to wear characteristics.
• Avoid in patients with metal hypersensitivity or renal impairment.

Surgical Mastery & Pearls

Stepwise Surgical Overview:

1. Exposure: Posterior or anterolateral approach; maintain soft tissue integrity to reduce dislocation risk.
2. Femoral Head Preparation: Precise head sizing and reaming to preserve femoral neck cortex; avoid over-reaming.
3. Acetabular Preparation: Accurate cup positioning (40–45° abduction, 15–20° anteversion) to minimize edge loading and metal wear.
4. Trialing: Confirm stability and leg length; assess impingement.
5. Implantation: Cement femoral component carefully to avoid thermal necrosis; ensure press-fit acetabular component.
6. Closure: Meticulous soft tissue repair to optimize stability.

Intraoperative Red Flags:

• Femoral neck cracks or fractures during preparation.
• Poor cement mantle or component malposition.
• Excessive bleeding or soft tissue damage.

Technical Tips:

• Use intraoperative fluoroscopy or navigation to optimize component alignment.
• Preserve the femoral neck vascularity by minimizing soft tissue stripping.
• Avoid varus positioning of the femoral component to reduce fracture risk.

Evidence-Based Synthesis

Landmark studies (e.g., Australian Orthopaedic Association National Joint Replacement Registry) demonstrate that HRA has superior survivorship in young males compared to THA, with lower dislocation rates and better functional outcomes. However, concerns about metal ion release and pseudotumor formation have tempered enthusiasm, especially in females and patients with smaller femoral heads.

Recent randomized controlled trials comparing HRA to modern THA show comparable mid-term outcomes but highlight the importance of patient selection. Meta-analyses confirm higher revision rates in females and older patients undergoing HRA.

Current consensus favors HRA in young, active males with good bone quality, while reserving THA for others. Ongoing research into alternative bearing surfaces and improved implant designs aims to expand indications safely.

Pro-Tip: Surgical Excellence in Hip Resurfacing

• Master femoral neck preservation: The integrity of the femoral neck is paramount; subtle cortical notching or over-reaming exponentially increases fracture risk.
• Component positioning is non-negotiable: Use navigation or robotic assistance when available to achieve ideal cup inclination and anteversion.
• Patient selection trumps all: Resist pressure to perform HRA outside strict indications; poor candidates have disproportionately high complication rates.
• Meticulous cementing technique: Avoid cement extrusion into the femoral neck and ensure uniform mantle thickness to prevent early loosening.
• Monitor metal ion levels postoperatively: Early detection of adverse reactions can prevent catastrophic failures.

This synthesis equips the orthopaedic learner with a focused, evidence-driven framework to identify appropriate candidates for hip resurfacing arthroplasty and execute the procedure with surgical precision.

Last Updated on January 26, 2026 by OrthoNet AI