Letter to the Editor: Is the Survivorship of Birmingham Hip Resurfacing Better Than Selected Conventional Hip Arthroplasties in Men Younger Than 65 Years of Age? A Study from the Australian Orthopaedic Association National Joint Replacement Registry.

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To the Editor, I read with great attention the paper entitled “Is the Survivorship of Birmingham Hip Resurfacing Better Than Selected Conventional Hip Arthroplasties in Men Younger Than 65 Years of Age? A Study from the Australian Orthopaedic Association National Joint Replacement Registry” [3] and I would like to make some comments. In this study, revisions were recorded as major or minor. Unfortunately, with the Birmingham hip resurfacing device, no minor revision was possible, as noticed by the authors. Indeed, minor revision is the replacement of a femoral head and liner, and major revision is the replacement of a component (cup or stem). The authors also discussed this point, but it would be logical to count only the total number of revisions without dividing them into minor or major. This would allow us to have a fair comparison that would reflect reality. Otherwise, it is obvious that the major revision rate of the Birmingham hip resurfacing prosthesis will always be much higher than in the THA group. The authors did not report the rate of dislocation [3]. We only know that the rate of instability after revision was 0% for the Birmingham hip resurfacing prosthesis versus 0.2% for the THA implant. Is this difference significant? The authors do not report it. Furthermore, could a hip dislocation that was reduced under general anesthesia not be considered a minor revision? A dislocation is always a serious complication for the patient and the surgeon. The authors do not discuss this point. The authors reported that the Birmingham hip resurfacing infection rate is lower than that observed with THA [3]. Indeed, two-stage re-implantation for the management of an infection after resurfacing is easier than that with a THA. Indeed, the cut of the femoral neck in the absence of a stem is identical to that after primary surgery with THA. In addition, hip resurfacing is less intrusive than THA, without extension into the femoral medullary space, and makes re-implantation of a THA stem very simple and secure in a healthy bone environment. Moreover, the biofilm surface area is smaller with resurfacing than with THA, and the intracapsular dead space is small [2]. Recently, some authors indicated that surgical debridement, antibiotics, and implant retention seems a more effective procedure for resurfacing than THA [1]. Another study showed that resurfacing of an infected hip seems to demonstrate better results and is a less-intrusive treatment than THA [2]. In this Australian national registry, it is possible to have mortality data. This would be very important in order to compare the two groups. Indeed, for the 4790 Birmingham hip resurfacing prostheses and the 2696 THA prostheses, the mortality rate is a major element of comparison for patients and surgeons. A registry must give recommendations for the choice of procedure and devices (cemented or uncemented THA or resurfacing) mainly based on implant survival [1].