A Consensus From The Advanced Hip Resurfacing Course, Ghent, June 2009 About Metal-on Metal Hip Resurfacing
K. De Smet, MD, Orthopaedic Surgeon1;
P. A. Campbell, PhD, Associate Professor2;
and H. S. Gill, DPhil, University Lecturer in
Orthopaedic Mechanics3 1 ANCA Medical Center
(AMC-Ghent), Krijgslaan 181, 9000 Ghent, Belgium.
2 UCLA/Orthopaedic Hospital, 2400 South
Flower Street, Los Angeles, California 90007, USA.
3 Nuffield Department of Orthopaedics,
Rheumatology and Musculoskeletal Sciences University of
Oxford, Botnar Research Centre, Nuffield Orthopaedic
Centre, Oxford OX3 7LD, UK.
We report the consensus of surgical opinions of an
international faculty of expert
metal-on-metal hip resurfacing surgeons, with
a combined experience of over 18,000 cases, covering
required experience, indications, surgical
technique, rehabilitation and the management
of problematic cases.
The last decade has seen an increased use of
metal-on-metal hip resurfacing arthroplasty
as an alternative to contemporary total hip
replacement (THR), especially for patients who wish to participate in high-demand activities.
Metal-on-metal bearings are also being used
more often for THR. In June 2009, the third
Advanced Resurfacing Course was held in Ghent, with a
faculty that included 21 orthopaedic surgeons
whose combined experience included over 18,000 metal-on-metal hip resurfacing arthroplasties. As the meeting served to bring together surgeons,
highly experienced in hip resurfacing, from
Australia, Europe and the Americas, the
opportunity was taken to establish consensus views on
issues of required experience, indications,
surgical technique and rehabilitation. The
aim of this annotation is to disseminate
these consensus findings in order to help surgeons who
are considering metal-on-metal bearings for
both resurfacing and conventional THR. The
findings are presented as a majority opinion, with the percentage of the faculty in agreement given
The use of metal-on-metal bearings for THR and
resurfacing presents a greater technical
challenge than that of conventional
metal-on-polyethylene bearings. The consensus
(81%) was that an orthopaedic surgeon should
have a minimum experience of 200 conventional THRs
before starting to use a metal-on-metal hip
resurfacing arthroplasty. Opinion varied on
the number of these operations needed to overcome the learning curve, and ranged from 20 (36%), to
50 (28%) and more than 50 (30%).
The overall view (100%) was that the ideal candidate for
an metal-on-metal hip resurfacing
arthroplasty is a relatively young man with
normal anatomy and primary osteoarthritis. Being female was not, by itself, a contra-indication
(89%), but use of a small femoral head (< 46
mm) was contra-indicated (70%). Being female
and wanting to have children was a contra-indication (66%), as was being female and having a metal
allergy (70%). Grossly abnormal anatomy,
regardless of gender, was also agreed to be a
contra-indication (83%). There was considerable debate about bone quality, the general view being that
‘good’ femoral bone is a prerequisite, but no
agreement was reached on a working definition
of acceptable quality.
The majority opinion (56%) was that the best type of
femoral placement guide is that which
encircles the femoral neck. There was general
agreement (63%) that the current acetabular placement jigs are inadequate. The overall preference (78%)
was for cementing the femoral component with
a thin cement mantle with fixation holes
drilled in the femoral bone, use of pulsed lavage, and reduction of the hip in less than eight minutes
from the start of mixing the cement.
Full weight-bearing can be allowed on the first
post-operative day (73%) and patients should
use crutches for as long as needed (57%). Six
weeks is the optimal time to return to normal
non-sporting daily activities (44%), and six
months for returning to impact sports such as
running or tennis (61%).
Managing problematic cases
It was difficult to achieve a consensus on this topic,
and only the broad recommendations of the
discussion are reported. It was generally
agreed that these patients need to be followed up and those with symptoms investigated. There was
no agreement on the diagnostic value of
measurements of metal ions, but it was felt
that ‘high’ concentrations of systematic
metal ions indicated a problem with the articulation.
Cross-sectional imaging and plain radiographs
are required for the investigation of a
symptomatic metal-on-metal bearing.
It is hoped that these consensus opinions will prove
useful to orthopaedic surgeons and will lead
to improved outcomes after surgery for hip