Clinical Orthopaedics and Related Research®

, Volume 472, Issue 7, pp 2217–2230 | Cite as

Hip Resurfacing versus Total Hip Arthroplasty: A Systematic Review Comparing Standardized Outcomes

  • Deborah A. MarshallEmail author
  • Karen Pykerman
  • Jason Werle
  • Diane Lorenzetti
  • Tracy Wasylak
  • Tom Noseworthy
  • Donald A. Dick
  • Greg O’Connor
  • Aish Sundaram
  • Sanne Heintzbergen
  • Cy Frank



Metal-on-metal hip resurfacing was developed for younger, active patients as an alternative to THA, but it remains controversial. Study heterogeneity, inconsistent outcome definitions, and unstandardized outcome measures challenge our ability to compare arthroplasty outcomes studies.


We asked how early revisions or reoperations (within 5 years of surgery) and overall revisions, adverse events, and postoperative component malalignment compare among studies of metal-on-metal hip resurfacing with THA among patients with hip osteoarthritis. Secondarily, we compared the revision frequency identified in the systematic review with revisions reported in four major joint replacement registries.


We conducted a systematic review of English language studies published after 1996. Adverse events of interest included rates of early failure, time to revision, revision, reoperation, dislocation, infection/sepsis, femoral neck fracture, mortality, and postoperative component alignment. Revision rates were compared with those from four national joint replacement registries. Results were reported as adverse event rates per 1000 person-years stratified by device market status (in use and discontinued). Comparisons between event rates of metal-on-metal hip resurfacing and THA are made using a quasilikelihood generalized linear model. We identified 7421 abstracts, screened and reviewed 384 full-text articles, and included 236. The most common study designs were prospective cohort studies (46.6%; n = 110) and retrospective studies (36%; n = 85). Few randomized controlled trials were included (7.2%; n = 17).


The average time to revision was 3.0 years for metal-on-metal hip resurfacing (95% CI, 2.95–3.1) versus 7.8 for THA (95% CI, 7.2–8.3). For all devices, revisions and reoperations were more frequent with metal-on-metal hip resurfacing than THA based on point estimates and CIs: 10.7 (95% CI, 10.1–11.3) versus 7.1 (95% CI, 6.7–7.6; p = 0.068), and 7.9 (95% CI, 5.4–11.3) versus 1.8 (95% CI, 1.3–2.2; p = 0.084) per 1000 person-years, respectively. This difference was consistent with three of four national joint replacement registries, but overall national joint replacement registries revision rates were lower than those reported in the literature. Dislocations were more frequent with THA than metal-on-metal hip resurfacing: 4.4 (95% CI, 4.2–4.6) versus 0.9 (95% CI, 0.6–1.2; p = 0.008) per 1000 person-years, respectively. Adverse event rates change when discontinued devices were included.


Revisions and reoperations are more frequent and occur earlier with metal-on-metal hip resurfacing, except when discontinued devices are removed from the analyses. Results from the literature may be misleading without consistent definitions, standardized outcome metrics, and accounting for device market status. This is important when clinicians are assessing and communicating patient risk and when selecting which device is most appropriate for individual patients.


Heterotopic Ossification Femoral Neck Fracture Revision Rate Adverse Event Rate High Revision Rate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Denis Ako-Arrey DAA; MHA, MPH (McMaster University, Hamilton, Ontario, Canada), and Monica Cepoiu-Martin MCM; MD (University of Calgary, Calgary, Alberta, Canada) for their work reviewing abstracts and full-text articles for this systematic review. We also thank Gavin Steininger BSc, MASc, PhD (University of Victoria, Victoria, British Columbia, Canada) for biostatistics expertise and assistance.

Supplementary material

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Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • Deborah A. Marshall
    • 1
    Email author
  • Karen Pykerman
    • 1
  • Jason Werle
    • 2
  • Diane Lorenzetti
    • 1
  • Tracy Wasylak
    • 3
  • Tom Noseworthy
    • 4
    • 10
  • Donald A. Dick
    • 5
  • Greg O’Connor
    • 6
  • Aish Sundaram
    • 6
  • Sanne Heintzbergen
    • 7
  • Cy Frank
    • 8
    • 9
  1. 1.Department of Community Health SciencesUniversity of Calgary, Health Research Innovation CentreCalgaryCanada
  2. 2.Division of Joint Reconstruction, Department of SurgeryUniversity of CalgaryCalgaryCanada
  3. 3.Strategic Clinical Networks & Clinical Care Pathways, Alberta Health ServicesCalgaryCanada
  4. 4.University of CalgaryCalgaryCanada
  5. 5.Bone & Joint Strategic Clinical Network, Alberta Health ServicesEdmontonCanada
  6. 6.University of AlbertaEdmontonCanada
  7. 7.Health Technology & Service ResearchUniversity of TwenteEnschedeThe Netherlands
  8. 8.Alberta Innovates Health SolutionsCalgaryCanada
  9. 9.Alberta Bone and Joint Health InstituteCalgaryCanada
  10. 10.Alberta Health ServicesCalgaryCanada

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