Hip resurfacing: is female gender an absolute or relative contraindication?

Abstract

Female gender is not a contraindication for resurfacing. In this article evidence to support the routine use of metal on metal (MoM) hip resurfacing in young women will be presented. When implant survivorship is studied in registries, hip resurfacing arthroplasty (HRA) often fares poorly when compared to total hip replacement (THR) because of a bias of inexperience of most surgeons with HRA. In HRA expert surgeon series implant survivorship is at least as good as in expert series of THR. Early in the development of HRA, it became clear that women had worse implant survivorship than men. For this reason, both surgeons and implant manufacturers began discouraging the use of HRA in women. But patient age is an even more crucial variable than gender in implant survivorship. With decreasing age, THR implant survivorship drops precipitously, while HRA implant survivorship is robust. For this reason, in young women, HRA implant survivorship actually surpasses THR implant survivorship. In retrospect, it may have been an error to deny HRA to young women. In this article, I will describe improvements in technique that have served to narrow the disparity of outcomes between genders (current Kaplan-Meier 12-year: 99.5% men and 98.5% women, 99% overall). Specifically, I will describe how failures due to metallosis have been overcome. These advances, which have disproportionately benefitted women, have driven my overall 10-year implant survivorship up from 89% to 99% in the last 20 years. When these refinements have been incorporated in the practice of a skilled HRA surgeon, there is no reason to deny young women the opportunity to enjoy the other benefits of HRA: bone preservation, less instability, no thigh pain, less unexplained pain, higher function, and lower all-cause mortality than stemmed THR. Unfortunately, most young patients are never informed of the option of HRA.