The Journal of Arthroplasty 32 (2017) 3647e3651

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Primary Arthroplasty

Birmingham Hip Resurfacing vs Total Hip Arthroplasty:

A Matched-Pair Comparison of Clinical Outcomes
Victor R. Ortiz-Declet, MD a, David A. Iacobelli, MD b, Leslie C. Yuen, BA a, Itay Perets, MD a,
Austin W. Chen, MD a, Benjamin G. Domb, MD a, c, *
a
American Hip Institute, Westmont, Illinois
b
Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
c
Hinsdale Orthopaedics, Westmont, Illinois

a r t i c l e i n f o a b s t r a c t

Article history: Background: Birmingham hip resurfacing (BHR) has proven to be a good alternative for younger patients with
Received 17 March 2017 osteoarthritis. Some have asserted that BHR may yield outcomes which are superior to total hip arthroplasty
Received in revised form (THA), and that some studies which failed to show a difference were plagued by ceiling effects and lack of
8 June 2017
sensitivity of outcome measures. The purpose of this study is to compare outcomes of BHR and THA using the
Accepted 16 June 2017
Available online 23 June 2017
“Forgotten Joint” Score-12 (FJS), a more sensitive score with lesser vulnerability to the ceiling effect.
Methods: Patients who underwent BHR were matched to patients who underwent posterior THA by
computing a propensity score using 5 covariates: age, body mass index, gender, worker's compensation
Keywords:
Birmingham hip resurfacing
claims, and previous hip surgery. Surgical outcomes were assessed using 6 patient-reported outcome
total hip arthroplasty measures, including the FJS, the visual analog scale for pain, and patient satisfaction.
forgotten joint score Results: There were 42 patients in the BHR group and 18 patients in the THA group. The FJS was 78.0 for
patient-reported outcomes the BHR group and 76.0 for the THA group. The Veterans RAND 12-Item Health Survey Mental
clinical outcomes Component Summary and Short Form 12 Mental Component Summary were significantly higher in the
BHR group. No differences were seen between all other patient-reported outcomes.
Conclusion: BHR offers excellent results in young patients that are comparable to THA. As no clinical
difference could be shown between BHR and THA, even with the use of the FJS, the choice between BHR
and THA should not be based solely on any expectation that either yields superior clinical outcomes
compared to the other at short-term follow-up.
© 2017 Elsevier Inc. All rights reserved.

Total hip arthroplasty (THA) is a proven method to treat
degenerative joint disease of the hip and it has become the most
successful surgery of the century [1]. However, conventional THA
implants have an estimated life span and they are not designed to
This study was performed at the American Hip Institute.
This study was approved by the Institutional Review Board (IRB ID: 5276).
One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.06.030.
Funding: This research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors.
* Reprint requests: Benjamin G. Domb, MD, 1010 Executive Court Suite 250
Westmont, IL 60559.
withstand high impact loads; thus, patients are recommended to
refrain from certain physical activities (ie, running) to theoretically
increase implant survivorship.
Birmingham hip resurfacing (BHR) has proven to be a good
alternative for younger patients with osteoarthritis who wish to
delay the need for conventional THA. BHR is currently the only
system approved by the US Food and Drug Administration and was
first made available for use in the United States in 2006 [2].
Although BHR is a relatively new treatment option in the United
States, it has been used in several other nations since 1997 [3].
Numerous studies have reported good medium-term survival
rates following BHR [3e8]. Oak et al and Brooks et al report high
midterm survival rates (98.8% and 99.2%, respectively) [3,6]. The
Oswestry International Register reports a 95% 10-year implant
survival rate for 5000 BHRs performed by 141 surgeons throughout
the world [5]. Daniel et al [5] reported an overall implant survival of
95.8% at 15 years.

http://dx.doi.org/10.1016/j.arth.2017.06.030
0883-5403/© 2017 Elsevier Inc. All rights reserved.
3648 V.R. Ortiz-Declet et al. / The Journal of Arthroplasty 32 (2017) 3647e3651
There are several proposed advantages of BHR compared to
conventional THA. First, BHR preserves more femoral bone, which
makes femoral revision less complicated [5,8]. It is important to
note that BHR offers particular advantages for young patients with
osteoarthritis. This includes the following: bone preservation,
keeps the patient's native hip biomechanics, has a low dislocation
rate, and the possibility of being able to continue engaging in high-
impact activities after surgery [5,8]. Whether high-impact activities
will increase the chance of mechanical failure remains to be seen.
Converting the femoral component after BHR to a THA is simpler
than a revision of a THA femoral component. When it comes to the
acetabulum, there are options: it could be revised to another shell,
due to the presence of fins on some of these cups this might make
the removal process slightly more difficult, but it would be similar
as revising a screwless cementless THA cup. There is also evidence
of leaving the well-fixed BHR cup and adding a dual-mobility
device to the femoral component [9,10], which would make the
revision process much simpler. Current dual-mobility devices have
good midterm follow-up in Europe [11].
Although younger, active patients have historically demon-
strated poorer outcomes following conventional THA, they are
shown to do very well with BHR [5,12,13]. BHR also results in better
functionality of the hip and a lower rate of component wear [5,8].
There is no consensus regarding the return to high-impact load
activities after BHR; however, preliminary data show that patients
can return to such activities without added risk of implant failure
[14,15]. Furthermore, BHR leaves patients with more anatomically
larger-sized components and more reliably reproduces the normal
hip biomechanics, which reduces the incidence of dislocation [5,8].
Although young patients have demonstrated good results with
BHR, some have raised concerns about the unique failure modes
related to these implants. Classically, aseptic loosening, particularly
of the femoral component, was a frequent reason for failure, but it
has been significantly reduced over the years with better patient
selection and improvement in surgical techniques [16].
Incidence of adverse reactions to metal debris (ARMD) arising
from hip resurfacing and THA metal-on-metal (MoM) bearing
surfaces is another current concern for failure. ARMD is an um-
brella term that includes the so-called pseudotumors and
hypersensitivity-induced necrosis, which have been linked to
joint arthroplasty failure [5,8,17]. Some studies have reported low
incidence of ARMD [5] whereas others have suggested ARMD as a
common reason for hip resurfacing failure [17]. Higher failure
rates have been seen in patients who are female, have smaller
femoral component head sizes, or have preoperative diagnoses
such as developmental dysplasia of the hip or avascular necrosis
of the femoral head. In addition to patient-related factors,
implant design plays a major role, as BHR has shown better
survival rates than other MoM resurfacing prosthesis [18e20].
Finally, malposition of the implants, particularly the cup, can
increase edge wear, leading to increased metal wear debris, and
ARMD [21]. As such, BHR is often recommended for males with
larger femoral anatomy and primary osteoarthritis and it should
be performed using tried-and-true components in the hands of
an expert surgeon [22].
THA is a well-established, successful surgical technique that has
resulted in excellent patient outcomes. Continued improvement in
THA has resulted in ceiling effects developing for many patient-
reported outcome (PRO) tools, making it difficult to distinguish
between patients with good outcomes and patients with excellent
outcomes [23e25]. The “Forgotten Joint” Score-12 (FJS) is a PRO
scale that assesses native and artificial joint awareness during
everyday life activities and is shown to have a much lower ceiling
effect compared to other PRO measures [23]. To our knowledge,
there are no existing studies that assess BHR outcomes using the
FJS. There is also a paucity in the literature comparing BHR out-
comes to conventional THA outcomes.
The purpose of this study is to compare outcomes of BHR and
posterior THA using the FJS, a more sensitive score with lesser
vulnerability to the ceiling effect. We hypothesized that there
would be no difference in FJS, as well as other PRO in patients who
underwent BHR as compared to those who underwent THA with a
similar approach.
Methods
Patient Selection Criteria
Data were prospectively collected and retrospectively reviewed
for all patients who underwent primary THA by the senior author
(B.G.D.) between September 2008 and April 2014. Patients were
included in the study group if they underwent BHR and patients
were included in the control group if they underwent nonrobotic,
posterior THA. The comparability of the BHR patients to the
posterior THA patients was then assessed by computing a pro-
pensity score. This propensity score was determined using a
multiple logistic regression model that incorporated the following
5 covariates: age, body mass index (BMI), gender, worker's
compensation claims, and previous hip surgery. The patients from
each group who did not match on the propensity score were
excluded from our analysis. This study was approved by the
institutional review board.
Indications for Surgery
All patients who underwent BHR or THA at our institution were
diagnosed with hip osteoarthritis based on their medical history,
physical examination, and imaging findings. Before surgical inter-
vention was recommended, all patients failed to improve with at
least 3 months of conservative treatment including rest, nonste-
roidal anti-inflammatory drugs, cortisone injections, and physical
therapy.
Surgical Technique
A hip posterior approach in the lateral decubitus position was
used for both BHR and THA. The MoM Birmingham Hip Resurfacing
(BHR) system from Smith and Nephew was used for all hip resur-
facing surgeries. The Smith and Nephew R3 acetabular shell and
Anthology stem were used with a polyethylene liner and ceramic
head for all THAs.
Outcome Evaluation
Surgical outcomes were evaluated using the following PRO
scores (all of which were scored from 0 to 100): the FJS, modified
Harris Hip Score, Veterans RAND 12-Item Health Survey (VR-12)
Physical (PCS) and Mental Component Summary (MCS) scales,
Short Form 12 (SF-12) Physical (PCS) and Mental Component
Summary (MCS) scales. Visual analog scale (VAS) was used to
evaluate pain level on a scale from 0 (no pain) to 10 (worst possible
pain) and patient satisfaction was rated out of 10 (10 ¼ highest
satisfaction). Outcome scores were obtained by one of the
following: clinical appointment, encrypted email, or telephone
interview.
Statistical Analysis
Comparability and matching between the BHR and THA subjects
were assessed by computing a propensity score using the 5
 V.R. Ortiz-Declet et al. / The Journal of Arthroplasty 32 (2017) 3647e3651 3649

Table 1 for the BHR group and 53.0 ± 8.3 years for the posterior THA group
Patient Demographics. (P ¼ .0812). Mean BMI was 30.0 ± 5.5 for the BHR group and
Clinical Variable BHR (N ¼ 42) Posterior THA P Value 29.4 ± 4.1 for the posterior THA group (P ¼ .9743). Two (4.8%)
(N ¼ 18) BHR and 1 (5.6%) posterior THA patients had worker's compen-
Hips included in study sation claims (P > .999). There were 3 (7.1%) patients in the BHR
Left 24 (57.1%) 10 (55.6%) 1.0000 group and 1 (5.6%) patient in the THA group who had previous
Right 18 (42.9%) 8 (44.4%) ipsilateral hip surgeries (P > .9999). Patient demographics are
Gender
summarized in Table 1.
Male 42 (100%) 18 (100%) 1.0000
Female 0 (0%) 0 (0%)
Age at surgery 49.1 ± 7.6 53.0 ± 8.3 .0812 Outcomes
(y; mean, SD)
BMI (mean, SD) 30.0 ± 5.5 29.4 ± 4.1 .9743
The median time to follow-up was 36.2 months (range,
Worker's compensation 2 (4.8%) 1 (5.6%) 1.0000
Previous ipsilateral hip 3 (7.1%) 1 (5.6%) 1.0000
14.0-93.7) for the BHR group and 62.3 months (range, 39.6-88.1) for
surgery the posterior THA group (P < .001). The only outcome measures
Follow-up time 36.2 (14.0-93.7) 62.3 <.0001 that were significantly different between the groups were the VR-
(mo; median, range) (39.6-88.1) 12 MCS and the SF-12 MCS. Mean VR-12 MCS was 63.4 ± 6.2 for
BHR, Birmingham hip resurfacing; THA, total hip arthroplasty; SD, standard devia- the BHR group and 57.7 ± 6.4 for the posterior THA group
tion; BMI, body mass index. (P ¼ .0002). Mean SF-12 MCS was 58.6 ± 5.9 for the BHR group and
54.1 ± 6.8 for the posterior THA group (P ¼ .002). The median FJS
covariates: age, BMI, gender, worker's compensation claims, and was 78 (range, 0-100) for the BHR group and 76.0 (range, 16.7-100)
previous hip surgery. The propensity score was computed by car- for the posterior THA group (P ¼ .504). All PROs, VAS, and patient
rying out a multiple logistic regression on BHR vs THA using all 5 satisfaction for both groups are documented in Table 2.
covariates simultaneously. Those who did not match on the pro-
pensity score were dropped as noncomparable in the adjusted Complications
comparison.
The Shapiro-Wilk test was used to test the data for normality. There were 2 (4.8%) complications reported in the BHR group:
Normal continuous data were compared using the 2-tailed Student one case of numbness on the lower portion of the surgical leg and
t-test and non-normal continuous data were compared using the one case of heterotopic ossification. There were no complications
nonparametric Wilcoxon rank-sum test. Categorical data were reported in the posterior THA group.
analyzed using Fisher exact test. The threshold for statistical sig-
nificance was set at 0.05. Means and standard deviations are Discussion
reported for normal continuous data and medians and ranges are
reported for non-normal continuous data. Analyses were carried THA is a proven surgical solution to the degenerative hip joint
out using SAS 9.4 and JMP 13.0 (SAS Inc, Cary, NC). disease [1]. BHR is a valid alternative in younger patients who are
more active and are more likely to undergo a revision hip recon-
Results structive surgery in their lifetime because it has the advantages of
femoral bone preservation, larger head, and reproduction of the
Patient Demographics native joint biomechanics with less risk of dislocation, and the
theoretical possibility of return to high-impact sports without
A total of 54 BHR patients and 61 posterior THA patients were added risk of early implant failure [14,15]. However, BHR does come
eligible for inclusion in our study. After computing a propensity with its own risks and modes of failure (femoral neck fracture,
score, 52 BHR patients and 22 posterior THA patients were found ARMD, among others), but the incidence of failure has significantly
to be comparable. Of these, 42 (80.8%) BHR patients and 18 (81.8%) decreased with better patient selection, well-manufactured
posterior THA patients had postoperative PRO measures recorded implants, and the hands of an experienced surgeon that can ach-
and were included in the study. All of the patients included in this ieve ideal implant position to avoid edge wear [16].
study were male. The average age at surgery was 49.1 ± 7.6 years Reports show that patients after BHR are more active than THA
patients [26], and BHR patients still engage in high-impact sport
activities after surgery [27,28]. For these reasons, there is a ten-
Table 2 dency of recommending BHR in younger active patients who wish
PROs, VAS, and Satisfaction at Latest Follow-Up.
to engage in such high-impact activities after surgery. However,
Patient-Reported Outcomes BHR (N ¼ 42) Posterior THA P Value there is a difference between what patients are able to do and what
(N ¼ 18) surgeons would advise them to do, in light of lack of evidence pa-
mHHS (median, range) 96.0 (46.0-100.0) 91.5 (40.0-100.0) .3767 tients should always be informed that high-impact activities may
FJS (median, range) 78.0 (0.0-100.0) 76.0 (16.7-100.0) .5043 decrease the life of their arthroplasty (BHR or THA). What surgeons
SF-12 Mental (mean, SD) 58.6 ± 5.9 54.1 ± 6.8 .0017 and patients might have in the back of their mind when patients
SF-12 Physical 51.5 (21.0-58.0) 48.5 (36.0-57.2) .2015
(median, range)
engage in high-impact sports is that eventually if their BHR fail,
VR-12 Mental (mean, SD) 63.4 ± 6.2 57.7 ± 6.4 .0002 they can undergo a conversion to THA.
VR-12 Physical 53.0 (21.0-58.0) 49.3 (38.3-58.6) .1111 PROs are used to determine the success of an intervention from
(median, range) a patient's point of view. However, the most commonly used PROs
VAS (median, range) 0.7 (0.0-6.0) 0.0 (0.0-3.0) .4332
have a ceiling effect which makes it difficult to differentiate good
Patient satisfaction 10 (5-10) 10 (7-10) .9093
(mean, SD) from excellent outcomes. For this reason, we measured the FJS
during the postoperative period, because it has a low ceiling effect
PROs, patient-reported outcomes; VAS, visual analog scale; BHR, Birmingham hip
resurfacing; THA, total hip arthroplasty; mHHS, modified Harris Hip Score; FJS,
and can separate good from excellent outcomes. The FJS measures
“Forgotten Joint” Score-12; SF-12, Short Form 12; VR-12, Veterans RAND 12-Item whether patients go about their activities of daily living or perform
Health Survey; SD, standard deviation. sports without even noticing their joint, and as Behrend et al [23]
3650 V.R. Ortiz-Declet et al. / The Journal of Arthroplasty 32 (2017) 3647e3651
showed when they validated this new tool, not even their healthy
control group with native knee and hip joints (matched to TKA and
THA patients) had a mean maximum score of 100.
We studied all patients who underwent BHR via a posterior
approach at our institution and matched those who had FJS and
PRO measured after surgery at a minimum of 2 years to a group of
patients who had THA. We matched patients according to their
preoperative age, BMI, gender, worker's compensation claims, and
history of prior hip operation. Both groups were relatively young
with an average age of 49.1 years for BHR and 53.0 years for THA,
which is expected because most of the patients selected for BHR are
young. In both groups, 100% were males, which again is expected
due to patient selection criteria for BHR. BMI did not differ and was
around 29-30 kg/m2, and most of our patients were considered
overweight but not obese. Both groups were similar regarding
worker's compensation status and prior hip surgery.
The BHR and THA group had similar median scores for their
postoperative PROs: modified Harris Hip Score (96.0 vs 91.5), VAS
for pain (0.7 vs 0.0), SF-12 PCS (51.5 vs 48.5), and VR-12 PCS (53.0 vs
49.3). These results compare very well to available literature
regarding postoperative outcomes after primary THA [29,30] and
further validate that patients who undergo BHR have outcomes
that are as good as after THA, but with the additional benefits
already mentioned of preserved femoral bone for possible future
revision due to their young age, decreased risk of dislocation, and
the possibility to perform high-impact activities without increasing
the risk of failure.
All PROs measured had similar average scores that did not differ
statistically, except for the SF-12 MCS and the VR-12 MCS, with the
BHR group having higher mean scores of 5.7 points (P < .001) and
4.5 points (P ¼ .002), respectively. It has been shown in multiple
studies that the preoperative MCS scores change minimally after
total joint arthroplasty [30,31]. Thus, although there was a statis-
tically significant difference between the 2 groups regarding their
postoperative MCS scores, these differences are probably not due to
the surgical intervention (ie, BHR did not improve the SF-12 and
VR-12 MCS postoperative scores 4 or 5 points more than THA did),
and it is more than likely that these differences were present pre-
operatively. Because we did not record these scores preoperatively,
we cannot reach further conclusions.
Both groups had similar FJS scores (P ¼ .504). Our BHR patients
had a median score of 78.0, whereas patients who had a THA had a
median score of 76.0. These scores are higher than those published
by Behrend et al [23] as mean score for males undergoing THA was
63.8 and for females undergoing THA was 54.7. When looking at the
healthy controls in the same study where the FJS score was validated,
males had a mean score of 86.6 and it was 79.3 for females. Younger
patients tend to have better scores in general, and males tend to have
higher PRO and FJS scores than females [32]. Because our patients
were younger around 50 years old vs 70 years old, and they were all
males vs an almost 50/50 distribution in the quoted study, these
differences could explain why our BHR and THA population had
higher FJS scores than those reported by Behrend et al [23].
Our study has some limitations; first it is a single-surgeon case
series of the United States, and these results should be interpreted
with caution when compared to other populations with different
demographics. In addition, the matched cohort of THA patients is
small because patients who undergo THA at our institution choose
between anterior and posterior approach, and also BHR was done
exclusively in males, and after matching BHR patients to the THA
group, all females on the latter group were excluded. However, there
is sufficient literature available that has recorded outcomes after
THA, and our small cohort is comparable to those studies. Finally, we
did not have preoperative PROs to compare the delta before and
after surgery and see whether 1 of the 2 groups (BHR vs THA) was
worst preoperatively and gained more with the surgery; we only
know that after the surgery they had similar final outcomes.
There are several strengths to our study. To our knowledge, this
is the first publication that uses FJS to evaluate outcomes after BHR
and further we compared them to a matched group of THA patients
to determine whether results were similar. Additionally, we had a
minimum follow-up of 2 years, and we had a follow-up rate of 80%.
Finally, we were able to record additional postoperative PRO to
further determine whether the outcomes between THA and BHR
were any different.
In conclusion, BHR offers excellent results in young patients that
are comparable to THA. As no clinical difference could be shown
between BHR and THA, even with the use of the FJS, which has a
very low ceiling effect, the choice between BHR and THA should not
be based solely on any expectation that either yields superior
clinical outcomes compared to the other at short-term follow-up.
BHR should be considered and discussed with younger patients
with large femoral anatomy because it has similar PROs as a THA in
our short-term follow-up, but it has the added benefits of being a
bone-preserving arthroplasty, sustaining the patient's biome-
chanics, having a low dislocation rate, and allowing an easier
revision of the components.
Acknowledgments
The authors thank Dr. Jeffrey Gornbein for his statistical guid-
ance and analysis.
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