by Todd P. Murphy, MD; Robert T. Trousdale, MD; Mark W. Pagnano, MD; Tad M. Mabry, MD; Rafael J. Sierra, MD
Abstract
The purpose of this study was to understand patients’ perceptions regarding hip resurfacing arthroplasty relative to conventional total hip arthroplasty (THA). A consecutive group of 139 patients being evaluated for hip symptoms were asked to complete a survey regarding hip resurfacing arthroplasty. Forty-one percent were aware of hip resurfacing arthroplasty, and 82% felt hip resurfacing arthroplasty was a safer procedure than THA. Seventy-nine percent felt there was less soft tissue damage associated with hip resurfacing arthroplasty, and 80% felt they would return to their activities more quickly. Eighty percent felt that their overall range of motion would be better following hip resurfacing arthroplasty.
Patients’ perceptions of hip resurfacing arthroplasty are inconsistent with the known published advantages and disadvantages of the procedure when compared to conventional THA. Most of the patients received their information from sources other than an orthopedic surgeon.
Hip resurfacing arthroplasty is a type of total hip replacement that has had a resurgence of interest. The early hip resurfacing designs (metal-on-polyethylene) had high early failure rates and fell out of favor as the techniques and long-term success rates of total hip arthroplasty (THA) with a stemmed femoral component improved. Recently, with advances in the component design and newer metal-on-metal bearing surfaces, there has been resurgence in the use of hip resurfacing arthroplasty to treat many arthritides. The current short-term follow-up data have shown good clinical results with relatively low failure rates of these newer designs.1-5 As such, hip resurfacing arthroplasty has regenerated substantial interest among patients and surgeons over the past several years.
We have observed that many patients have perceptions of hip resurfacing arthroplasty that are not supported by peer-reviewed literature. Furthermore, prior to evaluation and discussion of treatment options, many of these patients present with a strong emotional bias toward hip resurfacing arthroplasty.
We know of no data in the literature reporting how patients perceive the advantages and disadvantages of hip resurfacing arthroplasty as compared to conventional THA. The purpose of this study was to document patients’ perceptions about the potential benefits and drawbacks of hip resurfacing arthroplasty.
Materials and Methods
A group of consecutive patients were seen by 4 lower-extremity adult reconstructive surgeons (R.T.T., M.W.P., T.M.M., R.J.S.) and were asked to complete a survey concerning hip resurfacing arthroplasty. The survey and authorization forms were approved by our institutional review board. The survey was presented to the patients prior to evaluation by the treating surgeon. If the patient had not previously heard of hip resurfacing arthroplasty, the survey was stopped. If they had heard of hip resurfacing arthroplasty, they completed the survey.
Patients responded to questions, using a Likert-type scale,6,7 comparing conventional THA to hip resurfacing arthroplasty. The survey asked a series of questions about the risk of complications, the safety of the procedure, and the immediate and long-term outcome expectations. Patients were also asked how they had been informed of hip resurfacing arthroplasty and which type of hip replacement they would prefer (Figure).
Responses were examined and statistics were calculated with SAS software (version 9.0; SAS Institute, Cary, North Carolina).
Results
A total of 139 consecutive patients were given the survey. Fifty-seven patients (41%) were aware of hip resurfacing arthroplasty and completed the survey. Of those who completed the survey, 29 were men and 28 were women. Mean age of these 57 patients was 51 years (range, 17-98 years). The sources of the patients’ knowledge of hip resurfacing arthroplasty prior to evaluation are listed in Table 1. Patient perceptions of the expectations and outcomes of hip resurfacing arthroplasty are presented in Table 2.
Forty patients (40 of 49; 82%) felt hip resurfacing arthroplasty was a safer procedure than THA. Thirty-eight patients (38 of 48; 79%) felt there was less soft tissue damage associated with hip resurfacing arthroplasty, and 39 patients (39 of 49, 80%) felt they would return to their activities more quickly. Thirty-seven patients (37 of 46; 80%) felt their overall range of motion would be better with hip resurfacing arthroplasty.
Twenty-four patients (24 of 49; 49%) felt that conventional THA posed a greater risk of a major complication than hip resurfacing arthroplasty (2 of 49; 4%). Ten patients (10 of 49; 20%) felt that there was no difference and 13 (13 of 49; 27%) were unsure. Twenty-two patients (22 of 47; 47%) felt that conventional THA had greater risk leading to loosening of the prosthesis as compared to hip resurfacing arthroplasty (5 of 47; 11%). Six patients (6 of 47; 13%) felt there was no difference, and 14 patients (14 of 47; 30%) were unsure. When asked what type of hip replacement patients preferred, 26 (26 of 48; 54%) preferred hip resurfacing arthroplasty, 4 (4 of 48; 8%) preferred conventional THA, and 18 (18 of 48; 38%) were unsure.
Discussion
The data from this study demonstrate that most patients have many perceptions of hip resurfacing arthroplasty as it compares to conventional THA that are not supported by peer-reviewed data. In addition, prior to evaluation, patients were more likely to prefer a hip resurfacing arthroplasty (58%) than a conventional THA (8%). Interestingly, 81% of patients were informed of hip resurfacing arthroplasty by sources other than an orthopedic surgeon.
This strong predisposition toward hip resurfacing arthroplasty was further demonstrated by patients’ beliefs that their immediate postoperative and long-term functional outcomes would be superior with hip resurfacing arthroplasty. Patients had strong beliefs that hip resurfacing arthroplasty is safer, that they would have less chance of a complication, that their hospital stay would be shorter, and that there would be less soft tissue damage and postoperative pain. They also had strong beliefs that they would be able to return to their activities more quickly, that their range of motion would be better, and that they would be more likely to return to higher impact activities with hip resurfacing arthroplasty.
Clinical series comparing the short-term results of modern hip resurfacing prostheses (those involving a metal-on-metal bearing surface with cemented femoral fixation and cementless acetabular fixation) have been favorable,1,2,4 and for the most part are comparable with those of conventional THA.3,5 However, there are no reasonable (prospective blinded) data to support patients’ beliefs that hip resurfacing arthroplasty has lower complication rates or will provide better functional outcomes than conventional THA.
Hip resurfacing arthroplasty appears to be a promising alternative to conventional THA in appropriately selected patients. Patients are more educated about surgical options and expected outcomes than in the past because of the ready availability of educational resources. However, this study highlighted the fact that patient perceptions may not be accurate. Moreover, most of our patients developed their perceptions from sources other than an orthopedic surgeon. It seems as though surgeons, the industry, orthopedic societies, and the media have done a relatively poor job educating the public concerning the realities of hip resurfacing arthroplasty.
This study has some limitations. A sample of sequential patients from each hip surgeon’s practice participated in the study. Multicenter participation from other geographic regions may have revealed different attitudes toward hip resurfacing arthroplasty. In addition, the questions used to evaluate patient perceptions were not from a previously used, validated questionnaire.
Conclusion
This study suggests that a strong patient bias exists for hip resurfacing arthroplasty that is not supported by peer-reviewed literature. This has important implications when looking at clinical series (retrospective cohort series and randomized prospective series) comparing conventional THA and hip resurfacing arthroplasty. A continued effort should be made to emphasize known scientific data when considering the relative risks and benefits of hip resurfacing arthroplasty and conventional THA.
References
- Amstutz HC, Beaulé PE, Dorey FJ, Le Duff MJ, Campbell PA, Gruen TA. Metal-on-metal hybrid surface arthroplasty: two to six-year follow-up study. J Bone Joint Surg Am. 2004; 86(1):28-39.
- Daniel J, Pynsent PB, McMinn DJ. Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis. J Bone Joint Surg Br. 2004; 86(2):177-184.
- Pollard TC, Baker RP, Eastaugh-Waring SJ, Bannister GC. Treatment of the young active patient with osteoarthritis of the hip. A five- to seven-year comparison of hybrid total hip arthroplasty and metal-on-metal resurfacing. J Bone Joint Surg Br. 2006; 88(5):592-600.
- Treacy RB, McBryde CW, Pynsent PB. Birmingham hip resurfacing arthroplasty. A minimum follow-up of five years. J Bone Joint Surg Br. 2005; 87(2):167-170.
- Vail TP, Mina CA, Yergler JD, Pietrobon R. Metal-on-metal hip resurfacing compares favorably with THA at 2 years followup. Clin Orthop Relat Res. 2006; (453):123-131.
- Likert RA. A technique for the measurement of attitudes. Arch Psychol. 1932; (140):1-55.
- Wiersma W, Jurs SG. Research Methods in Education: An Introduction. 8th ed. London, England: Allyn and Bacon; 2004.
Authors
Drs Murphy, Trousdale, Pagnano, Mabry, and Sierra are from Mayo Clinic, Rochester, Minnesota.
Drs Murphy, Trousdale, Pagnano, Mabry, and Sierra have no relevant financial relationships to disclose.
Correspondence should be addressed to: Robert T. Trousdale, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
doi: 10.3928/01477447-20090818-10