HIP

A prospective comparative study of cementless

total hip arthroplasty and hip resurfacing in
patients under the age of 55 years
A TEN-YEAR FOLLOW-UP
F. S. Haddad,
S. Konan,
J. Tahmassebi
From University
College London
Hospitals, London,
United Kingdom

The aim of this study was to evaluate the ten-year clinical and functional outcome of hip
resurfacing and to compare it with that of cementless hip arthroplasty in patients under the
age of 55 years.
Between 1999 and 2002, 80 patients were enrolled into the study: 24 were randomised
(11 to hip resurfacing, 13 to total hip arthroplasty), 18 refused hip resurfacing and chose
cementless total hip arthroplasty with a 32 mm bearing, and 38 insisted on resurfacing. The
mean follow-up for all patients was 12.1 years (10 to 14).
Patients were assessed clinically and radiologically at one year, five years and ten years.
Outcome measures included EuroQol EQ5D, Oxford, Harris hip, University of California Los
Angeles and University College Hospital functional scores.
No differences were seen between the two groups in the Oxford or Harris hip scores or in
the quality of life scores. Despite a similar aspiration to activity pre-operatively, a higher
proportion of patients with a hip resurfacing were running and involved in sport and heavy
manual labour after ten years.
We found significantly higher function scores in patients who had undergone hip
resurfacing than in those with a cementless hip arthroplasty at ten years. This suggests a
functional advantage for hip resurfacing. There were no other attendant problems.
Cite this article: Bone Joint J 2015; 97-B:61722.

F. S. Haddad, BSc MD (Res),

FRCS (Tr&Orth), Professor of
Orthopaedic Surgery
University College London
Hospitals, 235 Euston Road,
London, NW1 2BU, UK.
S. Konan, MBBS, MD(res),
MRCS, FRCS(Tr&Orth),
Speciality Trainee, Department
of Orthopaedics
J. Tahmassebi, BSc,
Physiotherapy Extended Scope
Practitioner, Trauma and
Orthopaedics
University College London, 250
Euston Road, London, NW1
2BU, UK.
Correspondence should be sent
to Professor F. S. Haddad;
e-mail: fsh@fareshaddad.net
2015 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.97B5.
34537 $2.00
Bone Joint J
2015;97-B:61722.
Received 29 May 2014;
Accepted after revision 4
December 2014

VOL. 97-B, No. 5, MAY 2015

Total hip arthroplasty (THA) reliably relieves

pain and improves the function of patients
with end-stage hip disease.1 Hip resurfacing
has emerged as an alternative procedure for
this condition. Its suggested advantages are less
linear wear, preservation of bone stock, and an
excursion distance, which translates into
improved stability, and restoration of the
native anatomy and biomechanics.
The concerns with resurfacing have centred
on technique-specific complications such as
fracture and avascular necrosis, and adverse
reactions to the metal ions that are generated.
This has led to a dramatic reduction in the use
of hip resurfacing and to the withdrawal of
some implants.2-6 However, the Birmingham
Hip Resurfacing (BHR, Smith & Nephew,
Warwick, United Kingdom) remains in use, has
ten-year follow-up results, and has not been
associated with the level of failure noted with
some other resurfacing systems.7-9 In the
United Kingdom, the Orthopaedic Data Evaluation Panel (ODEP)10 ranks the BHR as 10A
(ten-year follow-up data with acceptable evidence to support its use).
The senior author (FSH) started performing hip resurfacing surgery in 1999. As the

long-term results had then yet to be established, a study was set up to compare the longterm outcomes of resurfacing with those of
THA. Because of the high expectations of this
patient population and the known ceiling
effects of well-established outcome measures,
we also looked at functional outcome in order
to assess the difference in hip function between
the two types of implant.11
We hypothesised that there was no difference between the long-term functional outcome of hip resurfacing and that of
uncemented primary THA in patients > 55
years, and that the two procedures were comparable in terms of operating time, analgesia
requirement and post-operative recovery.

Patients and Methods

Between 1999 and 2002, 80 patients were
enrolled in the study. Each patient was
reviewed in the senior authors clinic for endstage osteoarthritis (OA) and placed on the
waiting list. We excluded patients with a
high body mass index (> 40 kg/m2), an
American Society of Anesthesiologists12
(ASA) grade of 3 and above, or inflammatory arthritis.
617

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F. S. HADDAD, S. KONAN, J. TAHMASSEBI

Table I. Patient demographics

Actual implants
Gender (male/female)
Mean age (range) (yrs)

Group 1 (BHR)

Group 2 (THA)

33 BHR, 7 THA
30/10
47.8 (29 to 55)

24 THA, 16 BHR
29/11
48.2 (31 to 55)

BHR, Birmingham hip resurfacing; THA, total hip arthroplasty

Table II. Head sizes used for

Birmingham hip resurfacing
Head size

Numbers used

38
42
46
50
54
58

1
7
13
17
9
2

Patients were informed about resurfacing and cementless

THA. They were also given the option to participate in a
randomised controlled trial. Patients who were willing to
participate in the study and attend follow-up were included
once they had been through the process of informed consent (Table I). After completing this, 18 patients refused to
undergo hip resurfacing and chose cementless THA and 38
insisted on resurfacing. These patients were also followed
up and included in the study. Of the 80 patients, 24 consented to be randomised. Randomisation was undertaken
using sealed envelopes which were opened on the day of
surgery. A total of 11 patients (11 hips) were randomised to
hip resurfacing and 13 patients (13 hips) to THA.
The results were analysed based on intention to treat.
A single fellowship-trained arthroplasty surgeon with
established competence performed all procedures. Our
institutional review board approved the study.
Surgical procedure and implants. The BHR was used for all
patients undergoing resurfacing. The head sizes used are
summarised in Table II. A cementless, tapered hydroxyapatite (HA)-coated stem (Synergy, Smith & Nephew, Memphis, Tennessee) with a 32 mm cobaltchrome (CoCr) head
was used for cementless THA in conjunction with a hemispherical porous-coated cementless acetabular shell with a
polyethylene liner (Reflection, Smith & Nephew, Memphis,
Tennessee).
Surgery was carried out through a posterior approach,
with full capsular repair using transosseous sutures in every
case. A single drain was used and was removed 24 hours
later. All patients were given antibiotics (cefuroxime) on
induction and eight and 16 hours post-operatively. They
were also given low molecular weight heparin (enoxaparin,
Aventis Pharma, Dagenham, United Kingdom) until discharge. Blood transfusion was needed in eight patients in
the resurfacing group and six in the THA group. All
patients were allowed to mobilise fully weight-bearing

post-operatively, and were assessed by a physiotherapist

blinded to the procedure.
Clinical and radiographic assessment. All patients were followed up clinically and radiologically (two orthogonal views
of the hip) at one, five and ten years. Acetabular component
abduction angles were measured using PACS (Agfa HealthCare UK, Brentford, United Kingdom) tools on plain anteroposterior (AP) radiographs and anteversion angles using
cross-table radiographs.13 The mean follow-up in all 80
patients enrolled in this study was 12.1 years (10 to 14). At
the ten-year follow-up, MRI and metal ions studies were
obtained for all patients, except eight who declined to be
investigated.
Outcome measures. These included EuroQol EQ-5D,14 the
Oxford hip score (OHS),15 Harris hip score (HHS),16 University of California Los Angeles (UCLA) activity score,17 postoperative functional measures (detailed below) and the University College London Hospital (UCLH) function score.11
Post-operative recovery. In order to assess the postoperative function of both groups of patients, the patients
earliest ability to achieve the following tasks was documented by a physiotherapist blinded to the intervention
performed: knee flexion > 45; straight leg raise; active
abduction; standing; independent mobilisation out of bed;
independent transfer into bed; stair climbing; walking
> 20 metres; independent showering, and discharge from
hospital.
Primary outcome measures. Functional, quality of life and
hip-specific outcome scores at the ten-year follow-up visit
were set as the primary outcome measures. Secondary outcome measures included operating time, immediate postoperative functional recovery, clinical outcome and radiological outcome.
Statistical analysis. The differences in primary and secondary endpoints were analysed using the MannWhitney U
test on an intention to treat basis. A p-value < 0.05 was
used as a threshold for significance.

Results
The two groups had comparable demographic features
(Table I) and pre-operative scores (Table III).
Intra-operative and immediate post-operative outcomes. The
mean operating time (Fig. 1) was higher in the BHR group
(69 minutes; 50 to 110) than in the THA group (60 minutes;
36 to 90). This difference was not statistically significant
(p = 0.16).
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619

Table III. Comparison of the ten-year mean (standard deviation, (SD) outcome scores: Birmingham hip resurfacing (BHR) vs total hip
arthroplasty (THA)
THA

HHS
WOMAC
EQ5D
UCLA
OHS
UCH F
UCH D
UCH P

BHR

Pre-op scores

SD

Post-op scores

SD

Post-op scores

SD

Post-op scores

SD

43.2
51.2
0.31
5
18.1
78.53
72.11
76.53

12.1
22
0.33
2
7
10.9
7.82
7.44

96
6.16
0.81
8
37.9
63
46.9
20.79

4.2
19.1
0.03
1
0.6
12.4
9.4
7.3

53.9
46.7
0.32
5
19.1
79.11
73.21
77.81

13.9
19.2
0.34
2
7.8
12.1
9.2
8.2

97.1
3.24
0.85
8.12
40.1
30.34
18
11.93

5.1
15
0.05
1
0.4
15.1
17.3
13.4

HHS, Harris Hip Score; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; EQ-5D, EuroQol 5D; UCLA, University of California, Los Angeles; OHS, Oxford Hip score; UCH F, D, P, University College Hospital Function, Deformity, Pain

THA
BHR

Straight
leg raise

20 metre
walk

20

40

60

80

100

120

THA

Time (mins)
Fig. 1

BHR
Stair
climb

Box and whisker plots showing median comparison of operating time,

Birmingham hip resurfacing (BHR) versus total hip arthroplasty (THA).

There were no immediate post-operative complications

(infection, deep vein thrombosis, pulmonary embolism,
nerve injury or fractures). There was one dislocation in the
THA group, which was treated by closed reduction and a
straight knee brace for six weeks, followed by routine
physiotherapy. This patients subsequent recovery was
unremarkable.
The mean hospital stay was shorter in the BHR group
(mean 4.3 days; 2 to 10) than in the THA group (mean 6
days; 3 to 10). This difference was not statistically significant (p = 0.21).
Early post-operative functional outcome. In the immediate
post-operative period, the BHR group were quicker to
climb stairs and walk 20 metres but slower to achieve a
straight leg raise (Fig. 2).
Clinical assessment. Several patients showed a tendency to
reduce their activity over the ten years of the study. At the
ten-year follow-up, patients in the BHR group were more
likely to be involved in higher-level activities than those
who had undergone THA (Fig. 3). No failures or revisions
occurred in this cohort. In particular, none of the BHR
patients had metal ion-related complications.
Radiological assessment. Radiological analysis of both
cohorts of patients showed no evidence of change in
VOL. 97-B, No. 5, MAY 2015

Number of days
Fig. 2
Box and whisker plots showing comparison of early median functional
parameters, Birmingham hip resurfacing (BHR) versus total hip arthroplasty (THA).

implant position or radiolucency. The THA group showed

good osseointegration of stems with no signs of stem subsidence, and there was no osteolysis. In the BHR group,
there was evidence of thinning of the femoral neck in six
cases: this was not progressive, nor was impingement seen
in any case. The mean abduction angle in the THA group
was 47 (42 to 52) and 46 (41 to 51) in the BHR group.
The mean anteversion angle was 21 (15 to 24) in the THA
group and 20 (16 to 22) in the BHR group.
Metal ions or MRI scans. Blood Co and Cr ion levels were
available for 72 patients, 49 of whom had had THA and 23
BHR; eight patients refused the test. There were no significant differences between the two groups. Four patients
(two with each type of prosthesis) had raised Co and Cr levels at five years, but these were below the 7 ppb threshold
for concern.9 They remained static or reduced slightly
between five and ten years after surgery. In addition, six

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F. S. HADDAD, S. KONAN, J. TAHMASSEBI

120
THA

BHR

100

Operative time (mins)

THA

HHS

80
UCH F

60

UCH D

40
UCH F
20

UCH D
WOMAC
UCLA
EQ5D
2
3
4
5
Number of scores

10

BHR

UCH P
UCH P

UCLA scale
Fig. 3

Fig. 4

Ten-year University of California Los Angeles (UCLA) scale comparing

Birmingham hip resurfacing (BHR) with total hip arthroplasty (THA).

Graph showing the comparison of outcome scores between Birmingham hip resurfacing (BHR) and total hip arthroplasty (THA) (UCH F, D, P,
University College Hospital Function, Deformity, Pain).

Table IV. Comparison of functional tasks at ten-year-follow up between Birmingham hip

resurfacing (BHR) andtotal hip arthroplasty (THA)
Group

Support for single leg

stance (number of times)

Timed stair climb

x 10 steps (s)

Lateral step-up balance

assist (number of times)

THA
BHR

4.4
0.6

8.47
4.19

0.8
0.3

patients (four BHR, two THA) had small non-progressive

collections of trochanteric fluid. No adverse reactions to
metal debris or pseudotumours were noted on any of the
MRI scans in the 72 patients who had undergone testing for
metal ions. No cross-sectional imaging was ordered in the
remaining eight patients.
Outcome measures. No significant differences in hip score
were noted at one year or beyond between the two groups
using conventional outcome measures. However, the UCH
functional scale showed a difference in functional activity
(Fig. 4) between the groups. There was no difference in
quality of life scores at any stage. The ten-year results are
summarised in Table III.
Long-term functional differences between BHR and THA. In
spite of similar aspirations to activity pre-operatively, a
higher proportion of hip resurfacing patients were running and involved in sport and heavy manual work at
long-term follow-up. At ten years, seven patients (19.4%)
in the THA group were running compared with 26
patients (53.1%) in the BHR group (p = 0.1). With regard
to involvement in any sport, 16 patients (51.6%) in the
THA group were participating in the sport of their choice,
compared with 49 (85.7%) in the BHR group (p = 0.09).
A larger number of BHR patients (ten, 20.4%) were also
involved in heavy or manual work than in the THA group
(four, 12.9%; p = 0.19).
We have found significantly better (p < 0.001) function
scores using the UCH hip score (in the function, UCH F and
difficulty, UCH D subgroups) in resurfacing patients than
in THA patients (Table III).

At ten years, comparison of specific functional tasks

(Table IV) showed that the BHR group had better single leg
stance and hop, and better stair climbing endurance (anterior and lateral).

Discussion
Although our primary aim was to conduct a randomised
controlled trial comparing hip resurfacing and THA, this
was only possible in 24 patients. The other 56 insisted on
choosing the type of prosthesis before surgery and were
included in the study. Activity measures in this small cohort
of patients comparing THA and BHR suggest an advantage
to hip resurfacing.
In this group of patients we have not seen the dramatic
problems reported elsewhere3,18 with hip resurfacing. Our
data suggest that BHR is definitely not a lesser operation
than THA, as shown by the higher mean operating time
and the time lag in achieving a straight leg raise in the BHR
cohort. However, BHR patients recovered quickly, were
discharged from hospital earlier and had better long-term
function with a greater involvement in sports and heavy
manual work. However, our patients were young (< 55
years), and this may account for the results we observed.
There was no loss to follow-up. Our study suggests that
function after BHR is probably better than that after
cementless THA, but this is only seen with functional tasks
and activity-specific measures, not in the conventional
quality of life or hip outcome questionnaires.
There has been recent concern over the use of metal-onmetal articulations and this has resulted in a decline in the
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Table V. Summary of studies comparing hip resurfacing (HR) and total hip arthroplasty (THA)
n (hips)
Author

HR

THA

Mean follow-up (range)

Outcome measures

Better outcome in HR

Mont
Pollard24
Vail25

54
54
57

54
54
93

40 mths (24 to 60)

5 to 7 yrs
min 2 yrs, mean 3 yrs

HHS, activity levels

OHS, UCLA, EurQol
HHS, function, pain scores

Fowble26
Lingard27
Zyweil28

50
132

44
214
33

HHS, UCLA, function, SF-12

WOMAC, SF-36
Activity scores, HHS,
Patient satisfaction score, pain scores
PAT-5D index, WOMAC, SF-36, and UCLA
OHS, WOMAC HHS, activity score
WOMAC

Higher activity scores

Higher UCLA & EuroQol
Higher activity scores and range
of movement scores
Higher function, UCLA, SF-12
Higher SF-36 & WOMAC pain
Higher activity levels

HHS
OHS, HHS, QoL, disability rating, physical
activity level
HHS, UCLA

23

Garbuz31
Sandiford32
Venditolli29

33
48
141
109

56
141
100

2 to 4 yrs
1 yr
HR 42 mths (25 to 68)
THA 45 mths (24 to 67)
1.1 yrs (0.8 to 2.2)
HR 19.2 mths, THA 13.4 mths
56 mths (36 to 72)

Costa33
Costa34

73
60

137
66

min 2 yrs
12 mths

Issa30

120

120

42 mths (24 to 55)

No difference
No difference
Higher WOMAC functional at 1
and 2 years
No difference
No difference
Higher UCLA

HHS, Harris Hip score; SF, short form; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; UCLA, University of California Los
Angeles; QoL, quality of life; OHS, Oxford Hip Score; PAT-5D: paper adaptive test

number of resurfacing arthroplasties undertaken.19 However, with appropriate selection of both patient and
implant, and precise positioning of the implant, others have
reported excellent long-term outcomes for hip resurfacing.20 The BHR has not failed for the same reasons as other
metal-on-metal bearings,9,21 but as a result of wear and
edge loading, which are technique-specific. This is in contrast to large head metal-on-metal hip arthroplasties, where
corrosion and taper-related complications are welldocumented concerns.22
Summary of other studies. Table V summarises some of the
studies that have compared hip resurfacing with THA. Most
of these report the results of early follow-up. A functional or
quality-of-life advantage was noted by several of these.23-30
Some studies, however,31-34 reported no difference between
resurfacing and THA: two of these were randomised controlled trials.31,34 However, both of these studies looked at
early follow-up and did not use physical activity-specific outcome measures. Garbuz et al31 randomised 107 patients
deemed eligible for resurfacing arthroplasty to have either a
resurfacing or a large head metal-on-metal THA. Of the 73
patients followed for at least one year, both groups reported
an improvement in quality of life on all outcome measures
using quality of life and activity scores. The authors cautioned against the use of large-head THAs due to the excessively high metal ion levels compared with the resurfacing
group. Costa et al34 compared 60 hip resurfacings with 66
THAs. Intention-to-treat analysis showed no evidence for a
difference in hip function (HHS) between the treatment
groups at 12 months, but once again no activity-specific
measures were used.
The strengths of our study are the long-term follow-up
(ten years) and no loss to follow-up. Only 24 patients were
randomised, but this highlights the difficulty with clinical
studies comparing resurfacing with arthroplasty. A single

VOL. 97-B, No. 5, MAY 2015

surgeon who is a fellowship-trained, high-volume hip

surgeon performed all the procedures, and consequently
these results may not be reproducible. We acknowledge
that our study probably represents the best-case scenario,
with a preponderance of young male patients with large
femoral heads. We were also at a clinical advantage by
having chosen one of the better-performing hip resurfacing
implants. We acknowledge that the use of hip resurfacing
remains controversial with conflicting reports in the literature.20,35 However, based on our study, the functional
advantage of the BHR is apparent, but the economic and
quality-of-life sequelae of these results are more difficult to
assess.
Supplementary material
An appendix explaining the five tasks tested by the
University College London Hospitals Functional
Outcome Assessment System is available alongside the
online version of this article at www.bjj.boneandjoint.org.uk
Author contributions:
F. S. Haddad: Hypothesis generation, Data interpretation and presentation,
manuscript preparation.
S. Konan: Data Analysis, Manuscript preparation.
J. Tahmassebi: Data collection.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
This article was primary edited by A. Ross and first proof edited by G. Scott.

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