Journal Club

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Journal Club 20/02/2020 – Total Hip Replacement vs Hip resurfacing (Orthopaedics)

Total number = 5

BethC6:00 pm
Hello, here is the paper again just for reference!


Dr Kirolos Michael6:03 pm

Hi everyone, sorry for the slight delay. Shall we wait for a few more people?


BethC6:06 pm



Dr Kirolos Michael6:09 pm

shall we introduce and get going. People can join in later on


Dr Kirolos Michael6:09 pm

I’m Kirolos FY2 doctor


BethC6:09 pm

I’m Beth, 4th year medical student


Karan6:10 pm

I’m Karan, 3rd year medical student


Ashka6:10 pm

I’m Ashka, 3rd year medical student


Dr Kirolos Michael6:10 pm

Anybody interested in orthopaedics?


BethC6:11 pm

I’m currently on orthopaedics placement, it has its positives but not sure it’s the speciality for me!


Dr Kirolos Michael6:11 pm



Dr Kirolos Michael6:11 pm

How did everyone find this paper?


Dr Kirolos Michael6:11 pm

Let’s start with the background, can someone summarise what this study was about?


BethC6:13 pm

It was trying to determine if there was any difference between total hip replacement and resurfacing the acetabulum in terms of patient reported outcomes


Dr Kirolos Michael6:13 pm

That’s right


Dr Kirolos Michael6:13 pm

has anyone looked into what a total hip replacement is and what resurfacing is?


Ashka6:14 pm

Total hip replacement is removal of the head of femur and neck of femur whereas resurfacing involves capping the head of femur and leaving the neck intact?


Dr Kirolos Michael6:15 pm

Very good


Dr Kirolos Michael6:15 pm


Dr Kirolos Michael6:15 pm

This is a quick illustration of the differences


xenia sara6:16 pm

Hiya, sorry for joining late, I’m Xenia, 4th year medical student


xenia sara6:16 pm

As an initial thought I was quite surprised by the outcomes being similar for both approaches


Dr Kirolos Michael6:16 pm

So a THR involves removing the head and neck of the femur and replacing with a prosthesis that includes a femoral head and a stem while resurfacing involves putting a cap, essentially replacing the femoral head only, while preserving the neck k


Dr Kirolos Michael6:18 pm

The theory is that with resurfacing, you preserve the patient’s femoral neck, you preserve more of the native and therefore you would expect to get more physiological movement of the joint.


Dr Kirolos Michael6:18 pm

Hello Xenia


BethC6:19 pm

That makes sense, all I’ve heard from orthopods over the last few weeks is the importance of preserving joints before talking about replacements


Dr Kirolos Michael6:19 pm

So Beth nicely summarised the aims: i.e. difference between THR and resurfacing in terms of (A) hip function (B) quality of life


Dr Kirolos Michael6:19 pm

does anyone want to summarise the study design


xenia sara6:21 pm

So apparently it’s an assessor blind randomised controlled trial


Karan6:21 pm

Additionally its a single-centre study


xenia sara6:21 pm

Not entirely sure what two-arm parallel group means tbh


BethC6:21 pm

Single centre, blinded RCT with the THR being the control I assume?


Dr Kirolos Michael6:22 pm

Great guys, all correct


Dr Kirolos Michael6:22 pm

so it’s not double blinded. Because you have to consent people for different operations with slightly different risks etc.


Karan6:23 pm

I Believe a parallel arm study is when 2 groups, A & B, receive independent treatments with no crossover?


Dr Kirolos Michael6:23 pm

Two-arm means there are 2 interventions, parallel that these interventions are taking place at the same time, so not one after the other like a crossover


xenia sara6:23 pm

ahhh thank you both!


Dr Kirolos Michael6:23 pm

You summarised it better than me Karan


Dr Kirolos Michael6:24 pm

And what was the population of interest (i.e. selection criteria)?


xenia sara6:25 pm

>18, surgically fit & meet criteria for RSA


BethC6:25 pm

It’s not completely clear what the exclusion criteria is, but inclusion is >18 and fit for intervention as Xenia said


Dr Kirolos Michael6:26 pm

Yes. It seems like it’s anyone >18yrs who has severe arthritis who is fit enough for RSA & THR basically


xenia sara6:26 pm

Yeah I can’t see any definite exclusion criteria – apparently if they wouldn’t complete the study?


Dr Kirolos Michael6:27 pm

So just to clarify guys, with RSA, you replace the articular surface of the femoral head, but leave the neck intact. In both RSA and THR, you replace the articular surface of the acetabulum with a cup


Dr Kirolos Michael6:27 pm

Alright, moving on to the results, what did this study find?


Karan6:28 pm

It appears that both had relatively similar results in the years to follow


Karan6:28 pm

This study measured it by the Oxford Hip Score


Karan6:29 pm

Moreover, the complication rate and revisions are approximately the same as well


Ashka6:29 pm

There were no significant differences between THR and RSA in terms of the OHS and HR AOL scores


Dr Kirolos Michael6:30 pm

Great, so taking it one at a time


Dr Kirolos Michael6:31 pm

They looked at (1) Hip function. They used the Oxford Hip Score (OHS) which is a questionnaire that asks things like how difficult is it to get up from a chair, how easy is it to put on a pair of socks.… for those who want a closer look


Dr Kirolos Michael6:31 pm

And they found no difference at 5yrs in hip function between the 2 interventions. And over time, the OHS score decreased for both interventions but a similar proportion


Dr Kirolos Michael6:32 pm

Then they looked at (2) Quality of life. They used another questionnaire, the EuroQol EQ-5d


Dr Kirolos Michael6:33 pm

And also found no difference at 5yrs in terms of the quality of life and the rate of decline of quality of life over time between both interventions


Dr Kirolos Michael6:33 pm

Finally, they looked at (3) Revision rate at 5yrs


Dr Kirolos Michael6:33 pm

And found no statistically significant difference


BethC6:34 pm

So resurfacing as well as preserving as much of the joint as possible, performs similarly to THR and seems like the preferable option


Dr Kirolos Michael6:34 pm

Anybody surprised?


Dr Kirolos Michael6:35 pm

Well Beth, we’ll come to that in a bit. Because the study conclusion doesn’t really recommend


Ashka6:35 pm

But if the results are the same, would you not favour the cheaper option which is THR if I am not mistaken?


Dr Kirolos Michael6:35 pm

What are the strengths of the study?


Karan6:35 pm

I was a bit surprised to see the similarity in performance, especially with the decline. I would have imagined that with more of the native joint, it would result in a longer lasting effect?


Dr Kirolos Michael6:36 pm

It’s interesting


Dr Kirolos Michael6:37 pm

Any strengths or weaknesses?


Ashka6:37 pm

The strengths are different implants and surgical techniques used making the study more representative of the population, large number of participants and using validated patient reported outcome tools


BethC6:37 pm

The length of follow up plus using standardised questionairre’s are positives


Ashka6:38 pm

The weakness would be that the study cannot be double blinded?


BethC6:38 pm

Weakness also being single-centre


Dr Kirolos Michael6:39 pm

Really good strengths identified there from both of you


Dr Kirolos Michael6:39 pm

I guess the fact there are different surgeons, types of implants and surgical techniques make the results more generalisable to the wider population


Dr Kirolos Michael6:40 pm

But then it is only 1 centre and it couldn’t be double blinded


Dr Kirolos Michael6:41 pm

Also, while 122 is a good sample size, perhaps it isn’t that large given how many people have hip replacements ever year etc.


Dr Kirolos Michael6:42 pm

So to round things up. Does this study support resurfacing arthroplasty?


xenia sara6:43 pm



Ashka6:43 pm

I would say that it does not support RSA because of the similar results and the fact that THR is less costly?


Dr Kirolos Michael6:44 pm

So yes, the results don’t seem to favour it over total hip replacement


Dr Kirolos Michael6:44 pm

But is it worse?


xenia sara6:45 pm

In terms of patient outcomes they’re equal, in terms of practicality THS wins


Dr Kirolos Michael6:45 pm

Sure, so THR is certainly more cost effective, more people are doing it


Dr Kirolos Michael6:45 pm

One last point


Dr Kirolos Michael6:46 pm

Did anyone notice anything about materials used? (this was a very subtle statement)


Dr Kirolos Michael6:48 pm

Basically, with hip replacements, you can have different materials for the head and acetabular cup


Dr Kirolos Michael6:48 pm

it can be metal on metal, metal on ceramic etc.


Dr Kirolos Michael6:49 pm

with hip resurfacing, it is metal on metal only


BethC6:49 pm

Is that the reason for the greater expense at all?


Dr Kirolos Michael6:50 pm

when you have a metal ball articulating with a metal cup, you can imagine that over the years, you get abrasions and you end up with metal debris that causes inflammatory reactions around the joint and pseudo-tumours


Dr Kirolos Michael6:50 pm

this goes by a lot of names but is a recognised problem


Dr Kirolos Michael6:51 pm

with hip replacements, you can use metal on ceramic


BethC6:51 pm

I think I heard about this in an MDT recently, is it called Alval?


Dr Kirolos Michael6:52 pm

Very good Beth. Asceptic lymphocytic vasculitis association lesion (ALVAL)


Dr Kirolos Michael6:52 pm

it can be a real problem


Dr Kirolos Michael6:52 pm

with resurfacing, you’re stuck with metal on metal and therefore increased risk of ALVAL. With THR, you can avoid metal on metal articulations. Probably another reason to go for THR rather than resurfacing at this stage


BethC6:53 pm

So unless/until resurfacing can be done with alternative materials, there is no reason to change guidelines? I see


Karan6:54 pm

Is there any reason to use RSA at this moment then? Apart from surgeon preference perhaps?


Dr Kirolos Michael6:54 pm



Dr Kirolos Michael6:54 pm

Well, in younger patients in particular, THR rails after about 25rys (50% failure rate by that time).


Dr Kirolos Michael6:55 pm

Then you need a revision


Dr Kirolos Michael6:55 pm

That’s why we need to see if there are alternatives.


Dr Kirolos Michael6:55 pm

tThis is only 5 years in. Could this outlast THRs long term?


Dr Kirolos Michael6:56 pm

Could this be suitable as a solution prior to then going ahead with a THR a few decades down the line in younger patients? You preserve more of the anatomy for longer etc.


Dr Kirolos Michael6:56 pm

Only time will tell really


Dr Kirolos Michael6:57 pm

It may have many benefit, but based on this one study here and in this particular patient group, and looking only at a 5yr period and relying on just 2 self reported questionnaires, it would be hard to recommend resurfacing over THR


BethC6:58 pm

It could be, but then there’s the issue of how to decide an age cut-off in terms of what is meant by a ‘younger patient’/it may give rise to a grey area


Dr Kirolos Michael6:59 pm

absolutely. They didn’t really mention what people’s ages were or how that impacted any of these outcomes.


Dr Kirolos Michael6:59 pm

Any more thoughts or questions?


BethC7:01 pm

It would be interesting to see data on resurfacing vs THR depending on stage of osteoarthritis, I don’t really see them stratifying the patients in this study. Maybe the similar outcomes were because by chance they resurfaced milder cases of OA


Dr Kirolos Michael7:03 pm

That’s a very interesting thought. I guess by definition anyone, anyone who is having arthroplasty will have severe osteoarthritis that has failed conservative treatment. But would be very interesting to see in terms of how severe it was initially from a symptoms or radiographic point of view


Dr Kirolos Michael7:04 pm

Shall we wrap up then


BethC7:05 pm

Thank you Kirolos! Did you have any feedback forms for this session or future sessions?


Dr Kirolos Michael7:05 pm

Thanks guys. Hope it was useful. Let me know if you found the paper interesting, what you want to see more of etc. to help me with choosing further sessions. There’s now a plan of sessions with different specialities every session and a worksheet to help discussions


Dr Kirolos Michael7:07 pm

I don’t have feedback forms on me, are there any scalpel ones. Feel free to just post here guys any feedback for now


BethC7:08 pm

There will be formal feedback forms we can get for the next session if that’s okay! Can everyone who has been involved send me their email address so I can log who attended and know who to send feedback forms to over the course of Journal club this year?


Dr Kirolos Michael7:09 pm

Sounds good. Thanks Beth & the scalpel team for supporting


Karan7:09 pm

Thanks Dr. Kirolos! It was definitely an interesting read.


Ashka7:10 pm

Thank you Kirolos! This was very interesting!