Recent 10-year survivorship publications have an arthritis- or hip-specific QoL score but do not have these scores on all patients at baseline preoperatively, which precludes determination of so-called improvement from preoperative status [2, 5, 6, 17, 18, 30, 47, 54, 67]. Previous reports demonstrate the fixation of implants is excellent with low rates of implant failure [8, 27, 28, 34, 66].
Our study demonstrated patients with resurfacing were highly satisfied with their procedure and attained a high level of satisfaction across multiple domains including pain relief, function, and ability to participate in recreation. Few series to date report on a validated patient-reported satisfaction score. Coulter et al.  and Lingard et al.  reported high levels of satisfaction, with results comparable to our cohort of patients with resurfacing.
Our patients reported a mean UCLA activity score of 8 (range, 3-10), which supports activity-related results reported from other centers [2, 6, 9, 16-18, 30, 33, 47, 53, 54, 66]. Eighty-eight percent of our study patients attained a UCLA activity level of greater than 6, indicating a return to vigorous sporting activities.
There are two main modes of femoral failure after surface arthroplasty: neck fracture and aseptic loosening. The latter has a relatively low incidence of 1.2% [1, 2, 62, 63]. The incidence of fracture of the femoral neck in our study was 1.3% (two of 143 hips), which is relatively low and similar to the range of 0% to 2.5% reported in the literature [2, 5, 6, 8, 12, 16, 18, 25, 30, 33, 35, 48, 62, 67].
We observed a minority of patients in the study reported unexplained pain. All of them had a Durom® hip resurfacing. Revision to large-head metal-on-metal arthroplasty was performed in two patients. Component orientation was satisfactory and there was no radiographic or intraoperative evidence of loosening. Pathologic examination did not reveal femoral head osteonecrosis. The outcome after revision was disappointing in one patient who underwent a second socket revision to a metal-on-crosslinked polyethylene articulation for persistent pain after investigations showed a 7-cm cystic mass, which was deemed to be a pseudotumor. His function improved after removal of the metal-on-metal articulation. The other three patients were doing well in the first 4 years after the surgery, but then they started to experience activity-related pain. This was mild in one patient and severe in the other two patients. Infection was excluded and radiographs were unremarkable. These patients are currently under investigation and exploration will be performed if the symptoms increase or if there is MRI evidence of a reactive synovial cyst or pseudotumor. We classified these patients as at risk of failure and revision in keeping with our experience with this implant design in other patients outside of this study cohort. The late onset of similar symptoms in the nonstudy group, leading to exploration of the hip, revealed a loose cup due to fibrous fixation of the socket, although the radiographs were unremarkable with no signs of loosening. We have learned from this experience that the cup can be loose despite evidence of interface stability using conventional radiographic criteria. Similar experience with painful fibrous fixation of the Durom® cup, despite radiographic evidence of stability, has been reported from another center .
We remain cautious in the evaluation of these patients, as a number of concerns are beginning to emerge with metal-on-metal hip resurfacing, such as aseptic lymphocytic vasculitis-associated lesions (ALVALs) and pseudotumors [19, 21, 55, 72, 73]. It has to be stated the majority of complications in our series involved the Durom® system rather than the BHR™, suggesting there are substantial differences between implants and subtle implant design changes may lead to different outcomes. Nevertheless, the concerns regarding ALVAL and pseudotumor formation may be associated with any metal-on-metal hip arthroplasty system.
In conclusion, our patient-reported data demonstrated improvement from baseline preoperatively across domains of hip function, pain, stiffness, and generic QoL. In addition, the vast majority of patients remained highly satisfied and returned to a high level of sport and activity. Nevertheless, the rates of major complications and early revisions are certainly causes for concern. We recommend patients be advised of these risks alongside the benefits when considering hip resurfacing arthroplasty.
We thank Daphné Savoy for her assistance in the preparation of this manuscript and Abdul Aziz for his participation with patient followup and data collection for this study.
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