The clinical and radiological outcomes of hip resurfacing versus total hip arthroplasty: a meta-analysis and systematic review

Figures & data

Figure 1. PRISMA flow chart.

Figure 2. Funnel plot showing limited evidence of publication bias for the frequency of revision surgery.

Table 1. Demographic characteristics of randomized controlled trials

Paper	Hips		Patients		Mean age		Gender (M/F)		Follow-up period
	HRS	THA	HRS	THA	HRS	THA	HRS	THA	(months)
Garbuz et al. (2010)	48	56	48	56	52	52	43/5	50/6	Min. 12
Girard et al. (2008)	69	76	69	76	50	50	38/31	48/28	21
Girard et al.(2006)	49	55	49	55	47	48	31/18	34/21	N/S
Howie et al. (2005)	11	13	11	13	46	50	6/5	9/4	24
Lavigne et al. (2009)	24	24	24	24	50	50	14/10	5/9	14
Lavigne et al. (2008)	81	71	81	71	48	50	53/28	51/20	27
Rama et al. (2009)	103	97	103	97	50	50	65/38	66/31	12
Vendittoli et al. (2006)	107	103	107	103	49	51	67/40	70/33	Intra-op.
Vendittoli et al. (2010a)	64	53	64	53	49	51	42/22	33/20	24
Vendittoli et al. (2010b)	109	100	109	100	49	51	69/40	68/32	24

Intra-op.: intra-operatively; N/S: not stated; THA: total hip replacement.

Table 2. Demographic characteristics of retrospective studies

Paper	Hips		Patients		Mean age		Gender (M/F)		Follow-up period
	HRS	THA	HRS	THA	HRS	THA	HRS	THA	(months)
Brennan et al. (2009)	31	31	31	31	59	61	24/7	13/18	Intra-op.
Kim et al. (1987)	106	98	N/S	N/S	27	28	65/41	56/42	60
Meldrum et al. (2008)	141	125	118	103	47	47	80/32	58/45	Min. 14
Mont et al. (2009)	54	54	54	54	55	55	36/18	36/18	39
Naal et al. (2009)	362	181	N/S	N/S	N/S	N/S	250/112	125/56	Intra-op.
Pollard et al. (2006)	54	51	54	53	50	50	40/11	40/13	Min. 71
Swank and Alkire (2009)	128	105	128	105	51	N/S	100/28	N/S	24
Vail et al. (2006)	57	93	52	84	47	57	41/11	23/61	35

Intra-op.: intra-operatively; N/S: not stated; THA: total hip replacement.

Table 3. Demographic characteristics of observational studies

Paper	Hips		Patients		Mean age		Gender (M/F)		Follow-up period
	HRS	THA	HRS	THA	HRS	THA	HRS	THA	(months)
Ahmad et al. (2009)	28	28	28	28	54	61	14/14	10/18	N/S
Amstitz et al. (1984)	100	100	91	86	58	66	60/31	35/51	Min. 22
Chirodian et al. (2004)	44	50	44	50	48	52	28/16	22/28	12
Fowble et al. (2009)	50	44	50	35	46	55	31/19	18/26	Min. 24
Gore et al. (1985)	27	29	27	29	55	62	27	29	N/S
Gustilo et al. (1983)	75	91	67	75	75	49	N/S	N/S	82
Hall et al. (2009)	33	99	33	99	54	55	27/6	81/18	6
Hayaishi et al. (2007)	10	16	10	16	N/S	N/S	N/S	N/S	12
Kishida et al.(2004)	13	13	13	12	58	58	7/6	3/9	24
Langton et al. (2010) BHR	155	87	155	87	51	67	88/67	34/53	Min. 8
Langton et al. (2010) ASR	418	87	418	87	56	67	234/184	34/53	Min. 8
Le Duff et al. (2009)	35	35	35	35	53	53	24/11	24/11	88
Leonard et al. (2007)	40	85	40	85	N/S	N/S	N/S	N/S	N/S
Lilikakis et al. (2005)	35	41	33	40	53	65	20/13	14/26	0.3
Lingard et al. (2009)	132	214	132	214	49	67	90/42	90/146	12
Loughead et al. (2005)	28	26	28	26	50	62	N/S	N/S	N/S
Mont et al. (2007)	15	15	15	15	51	58	10/5	9/6	12
Mont et al. (2001)	30	30	30	30	34	35	18/12	18/12	84
Moroni et al. (2008)	25	27	20	26	49	48	10/10	12/14	Min. 24
Patel et al. (2009)	12	12	12	12	56	58	9/3	9/3	6
Pattyn and De Smet (2008)	250	190	250	190	50	45	N/S	N/S	Min. 36
Ritter and Gioe (1986)	50	50	50	50	62	62	27/23	27/23	Min. 60
Robb et al. (2009)	30	30	30	30	55	67	18/12	12/18	N/S
Silva et al. (2004)	50	40	50	32	47	54	31/19	12/20	N/S
Stulberg et al. (2009)	337	266	337	266	50	53	228/109	165/101	Min. 24
Wagner and Wagner (1996)	35	70	35	70	36	50	4/31	19/51	Min. 34
Witzleb et al. (2006)	111	88	111	74	51	54	N/C	N/C	N/C
Zywiel et al. (2009)	33	33	33	33	53	53	23/10	23/10	Min. 42

Table 4. Summary of the hip resurfacing prostheses used in the studies included in this systematic review

Birmingham Hip Resurfacing system (Smith and Nephew, Warwick, UK)	15
Durom hybrid resurfacing system (Zimmer, Warsaw, IN)	8
Conserve Plus (Wright Medical Technology, Arlington, TN)	6
Cormet MoM (Corin, Cirencester, UK)	4
Tharies prosthesis	2
Indiana Conservative SR	2
McMinn acetabular component and mini stemmed McMinn femoral resurfacing component (Corin Medical Ltd., Gloucestershire, UK)	1
Articular Surface Replacement (DePuy International Ltd., Leeds, UK)	1
Stemless resurfacing system (DePuy, Warsaw, IND)	1
MoM Metasul articulating surfaces prostheses	1
Not stated	2

Table 5. Summary of the total hip arthroplasty prostheses used in the studies included in this systematic review

Implant	Frequency
Metasul femoral head and M/L Taper stem (Zimmer, Warsaw, IN)	3
THR (Stryker-Howmedica-Osteonoics) Trident cup and Accolade femoral component (ceramic or cobalt chrome heads on PE liner	2
Trapezoidal-28 THA	2
Cemented CPS stem (Plus Orthopedics, Swindon, UK) and EPF uncemented acetabular component (Plus Orthopedics)	1
Trident Acetabular component and uncemented THA	1
Ultima cemented femoral stem and Duraloc acetabular component (DePuy, Leeds, UK)	1
Uncemented Birmingham Hip Resurfacing acetabular cup and Freeman stem (Finsbury, Surry, UK)	1
Exeter stem and PE acetabular component (Howmedica, London, UK)	1
Axcel THA (Axcel, Cremascoli, Milan, Italy)	1
Summit and Pinnacle uncemented stem (DePuy Orthopaedics Inc, Warsaw, IN) with Marathon PE acetabular (DePuy Orthopaedics Inc.) or Metal acetabulum (Ultamet; DePuy Orthopaedics Inc.)	1
CLS Spotorno grit-blasted titanium uncemented femoral stem and Metasul femoral head (Zimmer, Winterthur, Switerland)	1
Charnley and T-28 prostheses	1
ASR with Corail or SROM stem (DePuy International Ltd., Leeds, UK)	1
CLS femoral stem (Zimmer, Warsaw, IN) and Durom acetabular component	1
Stemmed THR	1
Exeter stem and conteoporary cup (Stryker, Howmedica, Newbury, UK) or Corail stem and ASR cup (DePuy International Ltd., UK)	1
Uncemented Trident Acetabular System and Accolade Femoral Hip System (Stryker-Howmedica-Osteonics, Allendale, NJ)	1
Exeter stem (Stryker, Howmedica, Newbury, UK) and ABG II (Stryker, Howmedica) or Trilogy acetabular component (Zimmer, Warsaw, IN)	1
Stemmed THA	1
PCA stem and System 12 acetabular cup (Stryker-Howmedica-Osteonics, Allendale, NJ)	1
Metasul MoM THR (Sulzer Orthopedics Ltd., Winterthur, Switzerland)	1
Allofit cup (Zimmer, Warsaw, IN)	1
Hybrid THA of Spectron cemented femoral component (Smith and Nephew Orthopaedics, UK), with Triology uncemented acetabular component (Zimmer Ltd., UK)	1
Ancafit CoC THA (Wright Medical, Arlington, TN)	1
Hybrid THA with PE liner	1
Metasul acetabular liner and femoral head (Zimmer, Warsaw, IN)	1
Exeter stem (Stryker, UK) with polyethylene Opera acetabular cup (Smith and Nephew, UK). Cemented procedure	1
CoC Stryker ABC System (Stryker Orthopaedics, Mahwah, NJ)	1
Uncemented - G2 femoral stem and Duraloc or Pinnacle cup (DePuy Orthopedics, Warsaw, IN) for metal on PE implant	1
CLS Spotorno (Zimmer, Warsaw, IN) Allofit acetabular shell (Zimmer), Metasul acetabular PE insert. 28-mm femoral head. Uncemented	1
MoM Cone prosthesis and CLS stem (Protek AG, Berne, Switzerland)	1
MoM THA (Metasul; Sulzer Orthopedics Ltd., Switzerland)	1
Not Stated	5

CoC: ceramic-on-ceramic; MoM: metal-on-metal; PE: polyethylene; THR: total hip replacement.

Table 6. Clinical outcomes after meta-analysis

Outcome	Mean difference	p-value	Heterogeneity
	(95% CI)		I^2 (%)	Chi^2
Last reaming required	0.78 (-0.22 – 1.78)	0.1	70	0.07
Mean incision length	6.42 (-0.49 – 15.33)	0.2	94	< 0.001
Duration of operation	13.63 (7.48 – 19.79)	< 0.001	74	0.004
Estimated blood loss	-152 (-305 – -0.5)	< 0.05	78	0.01
Length of hospital stay	-1.44 (-2.34 – -0.55)	0.002	93	< 0.001
Merle d'Aubigne index	-0.08 (-0.23 – 0.07)	0.3	0	0.61
UCLA	0.72 (-0.27 – 1.71)	0.2	90	< 0.001
Short Form-12 (mental)	1.90 (-8.25 – 4.04)	0.1	0	0.68
Short Form-12 (physical)	3.54 (0.60 – 6.48)	0.02	41	0.18
EQ-5D	0.03 (-0.05 – 0.11)	0.5	N/E	N/E
Patient satisfaction	N/E	N/E	N/E	N/E
Patient satisfaction (satisfied/very satisfied)	1.13 (0.94 – 1.35)	0.2	87	0.07
HHS	2.51 (1.24 – 3.77)	< 0.001	28	0.25
HHS (Function)	N/E	N/E	N/E	N/E
WOMAC	-2.41 (-3.88 – -0.94)	0.001	0	0.77
Oxford hip score	-4.13 (-7.41 – -0.86)	0.6	34	0.22
HHS (ROM)	-0.05 (-0.07 – -0.03)	< 0.001	N/E	N/E
Flexion ROM	-0.23 (-3.78 – 3.31)	0.9	0	0.58
Abduction ROM	-0.31 (-2.16 – 1.55)	0.8	0	0.51
Adduction ROM	3.00 (-0.92 – 6.92)	0.1	N/E	N/E
Internal rotation ROM	2.00 (-4.27 – 8.27)	0.5	N/E	N/E
External rotation ROM	1.00 (-3.51 – 5.51)	0.7	N/E	N/E
Total rotation ROM	-3.83 (-17.50 – 9.85)	1.0	79	0.03
Hop test	0.94 (0.16 – 7.53)	0.9	87	0.005
Step test	0.26 (0.12 – 0.55)	< 0.001	0	0.85
Pain ^a	-0.14 (-0.35 – 0.06)	0.2	0	0.36
Presence of groin pain	0.30 (0.59 – 5.27)	0.2	39	0.20
Presence of thigh pain	0.48 (0.09 – 2.55)	0.4	N/E	N/E
Frequency of blood transfusion requirement	0.37 (0.23 – 0.61)	< 0.001	0	0.97

^a standardized mean difference.

HHS: Harris hip score; N/E: not estimable; ROM: range of motion.

Table 7. Radiological outcomes following meta-analysis

Outcome	Mean difference	p-value	Heterogeneity
	(95% CI)		I^2 (%)	Chi^2
Femoral offset	-15.49 (-48.31 – 17.33)	0.4	100	< 0.001
Acetabular cup offset	2.20 (-0.95 – 5.35)	0.2	N/E	N/E
Leg length ^a	-0.62 (-1.48 – 0.24)	0.2	93	< 0.001
Cup height	N/E	N/E	N/E	N/E

^a standardized mean difference

N/E: not estimable.

Table 8. Radiology outcomes (dichotomous) following meta-analysis

Outcome	Risk ratio	p-value	Heterogeneity
	(95% CI)		I^2 (%)	Chi^2
Heterotopic ossification	1.62 (1.23 – 2.14)	< 0.001	16	0.3
Acetabular radiolucency present	1.27 (0.18 – 8.78)	0.8	60	0.1
Femoral radiolucency present	0.72 (0.03 – 19.47)	0.8	82	0.004

Figure 3. Forest plot to illustrate the difference in frequency of revision surgery between hip resurfacing and total hip replacement.

Figure 4. Forest plot to illustrate the difference in frequency of aseptic loosening between hip resurfacing and total hip replacement.

Table 9. Complication outcomes following meta-analysis

Outcome	Risk ratio	p-value	Heterogeneity
	(95% CI)		I^2 (%)	Chi^2
Femoral neck notching	9.2 (2.4–34.7)	0.001	0	0.9
Avascular necrosis	6.8 (1.7–27.6)	0.01	0	0.6
Aseptic loosening	3.1 (1.1–8.5)	0.03	52	0.03
Revision surgery	1.7 (1.2–2.5)	0.003	30	0.1
Positive Trendelenburg sign	1.7 (0.4–7.0)	0.5	0	0.8
Acetabular malposition	1.5 (0.7–3.1)	0.3	0	0.8
Peroneal nerve plasy	1.2 (0.3–5.6)	0.8	0	0.7
Mortality	1.1 (0.1–17.8)	0.9	62	0.1
Clinical leg length discrepancy	1.1 (0.2–7.4)	0.9	29	0.2
Fracture	0.9 (0.5–1.7)	0.8	0	0.7
Squeaking	0.9 (0.04–18.5)	0.9	51	0.2
Trochanteric bursitis	0.9 (0.1–8.1)	0.9	46	0.2
DVT-PE	0.8 (0.3–2.0)	0.6	0	0.7
Trochanteric malunion	0.8 (0.2–2.6)	0.7	0	0.6
Sciatic nerve palsy	0.7 (0.2–3.1)	0.6	0	0.6
Joint infection	0.5 (0.2–2.8)	0.1	0	0.8
Adverse reaction to metal debris failure	0.2 (0.02–2.5)	0.2	62	0.1
Dislocation	0.2 (0.1–0.5)	< 0.001	0	0.9

DVT-PE: Deep vein thrombosis and pulmonary embolism

Table 10. Summary of the CASP appraisal results

CASP score (maximum 17)	Frequency
0–3	1
4–7	16
8–11	23
12–15	5
16–17	0

Garbuz DS, Tanzer M, Greidanus NV, Masri BA, Duncan CP. Metal-on-metal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty. A randomized clinical trial. Clin Orthop 2010: (468): 318-25.

 PubMedGoogle Scholar

Girard J, Vendittoli PA, Roy AG, Lavigne M. Analyse de l'influence de l'offset fémoral sur la fonction clinique lors d'une étude prospective randomisée comparant les arthroplasties totales de hanche aux resurfaçages. Rev Chir Orthop Reparatrice Appar Mot 2008; 94(4):376-81.

 PubMedGoogle Scholar

Girard J, Lavigne M, Vendittoli P-A, Roy AG. Biomechanical reconstruction of the hip. A randomised study comparing total hip resurfacing and total hip arthroplasty J Bone Joint Surg (Br) 2006; 88(6):721-6.

 PubMedGoogle Scholar

Howie DW, McGee MA, Costi K, Graves SE. Metal-on-metal resurfacing versus total hip replacement – the value of a randomized clinical trial. Orthop Clin (Am) 2005; 36(2):195-201.

 PubMedGoogle Scholar

Lavigne M, Masses V, Girard J, Roy AG, Vendittoli PA. Activités sportives après resurfaçage et prothèse totale de hanche: une étude prospective randomisée. Rev Chir Orthop Reparatrice Appar Mot 2008; 94(4):361-7.

 PubMedGoogle Scholar

Rama KRBS, Vendittoli P-A, Ganapathi M, Heterotrophic ossification after surface replacement arthroplasty and total hip arthroplasty. A randomized study. J Arthroplasty 2009; 24(2):256-62.

 PubMedGoogle Scholar

Vendittoli PA, Lavigne M, Roy A, Mottard S, Girard J, Lusignan D. Metal ion release from bearing wear and corrosion with 28 mm and large-diameter metal-on-metal bearing articulations. A follow-up study. J Bone and Joint Surg (Br) 2010a; 92(1):12-9.

 PubMedGoogle Scholar

Vendittoli PA, Ganapathi M, Roy AG, Lusignan D, Lavigne M. Randomised study comparing THA and hip resurfacing. Currently unpublished manuscript: 2010b.

 Google Scholar

Brennan SA, Harty JA, Gormley C, O'Rourke SK. Comparison of acetabular reaming during hip resurfacing versus uncemented total hip arthroplasty. J Orthop Surg 2009; 17(3):42-6.

 Google Scholar

Kim WC, Grogan T, Amstutz HC, Dorey F. Survivorship comparison of THARIES and conventional hip arthroplasty in patients younger than 40 years old. Clin Orthop 1987; (214):269-77.

 PubMedGoogle Scholar

Meldrum RD, Maiers GP, Feinberg JR, Long-term outcome of surface replacement with comparison to an age- and time-matched primary total hip arthroplasty cohort. J Arthroplasty 2008; 23(1):1-9.

 PubMedGoogle Scholar

Mont MA, Marker DR, Smith JM, Ulrich SD, McGarth MS. Resurfacing is comparable to total hip arthroplasty at short-term follow-up. Clin Orthop 2009; (467):66-71.

 PubMed Web of Science ®Google Scholar

Naal FD, Kaim MSH, Hersche O, Munzinger U, Leunig M. Does hip resurfacing require larger acetabular cups than conventional THA? Clin Orthop 2009; 467 (4): 923-8.

 PubMedGoogle Scholar

Pollard TCB, Baker RP, Eastaugh-Waring SJ, Bannister GC. Treatment of the young active patients 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.

 PubMedGoogle Scholar

Swank ML, Alkire MR. Minimally invasive hip resurfacing compared to minimally invasive total hip arthroplasty. Bull NYU Hosp Jt Dis 2009; 67(2):113-5.

 PubMedGoogle Scholar

Vail TP, Mina CA, Yergler JD, Pietrobon R. Metal-on-metal hip resurfacing compares favourably with THA at 2 year follow-up. Clin Orthop 2006; (453):123-31.

 PubMedGoogle Scholar

Ahmad R, Gillespie G, Annamalai S, Leg length and offset following hip resurfacing and hip replacement. Hip Int 2009; 19(2):136-40.

 PubMedGoogle Scholar

Chirodian N, Saw T, Villar RN. Results of hybrid total hip replacement and resurfacing – is there a difference? Hip Int 2004; 14 (2): 169-73.

 PubMedGoogle Scholar

Fowble VA, dela Rosa MA, Schmalzried TP. A comparison of total hip resurfacing and total hip arthroplasty. Patients and outcomes. Bull NYU Hosp Jt Dis 2009; 67(2):108-12.

 PubMedGoogle Scholar

Gore DR, Murray MP, Gardner GM, Sepic SB. Hip function after total vs. surface replacement. Acta Orthop Scand 1985; 56(5):386-90.

 PubMedGoogle Scholar

Gustilo RB, Mendoza RM, Burnham WH. Long term results of total hip arthroplasty in younger age group. Comparative analysis with young arthroplasty patients. Orthopedics 1983; 6(1):60-9.

 PubMedGoogle Scholar

Hall DP, Srikantharajah D, Anakwe RE, Gaston P, Howie CR. Patient-reported outcome following metal-on-metal resurfacing of the hip and total hip replacement. Hip Int 2009; 19(2):245-50.

 PubMedGoogle Scholar

Hayaishi Y, Miki H, Nishii, T, Proximal femoral bone mineral density after resurfacing total hip arthroplasty and after standard stem-type cementless total hip arthroplasty, both having similar neck preservation and the same articulation type. J Arthroplasty 2007; 22(8):1208-13.

 PubMedGoogle Scholar

Kishida Y, Sugano N, Nishii T, Preservation of the bone mineral density of the femur after surface replacement of the hip. J Bone Joint Surg (Br) 2004; 86(2):185-9.

 PubMedGoogle Scholar

Langton DJ, Jameson SS, Joyce TJ, Early failure of metal-on-metal bearings in hip resurfacing and large-diameter total hip replacement: A consequence of excess wear. J Bone Joint Surg (Br) 2010; 92(1):38-46.

 PubMedGoogle Scholar

Le Duff MJ, Wisk LE, Amstutz HC. Range of motion after stemmed total hip arthroplasty and hip resurfacing. A clinical study. Bull NYU Hosp Jt Dis 2009; 67(2):177-81.

 PubMedGoogle Scholar

Leonard M, Magill P, Kiely P, Khayyat G. Radiologic comparison of cemented and uncemented total hip arthroplasty and hip resurfacing. Eur J Orthop Surg Traumatol 2007; 17(6):583-6.

 Google Scholar

Lilikakis AK, Arora A, Villar RN. Early rehabilitation comparing hip resurfacing and total hip replacement. Hip Int 2005; 15(4):189-94.

 PubMedGoogle Scholar

Lingard EA, Muthumayandi K, Holland JP. Comparison of patient-reported outcomes between hip resurfacing and total hip replacement. J Bone Joint Surg (Br) 2009; 91(12):1550-4.

 PubMedGoogle Scholar

Loughead JM, Chesney D, Holland JP, McCaskie AW. Comparison of offset in Birmingham hip resurfacing and hybrid total hip arthroplasty. J Bone Joint Surg (Br) 2005; 87(2):163-6.

 PubMedGoogle Scholar

Mont MA, Seyler TM, Ragland PS, Gait analysis of patients with resurfacing hip arthroplasty compared with hip osteoarthritis and standard total hip arthroplasty. J Arthroplasty 2007; 22(1):100-8.

 PubMed Web of Science ®Google Scholar

Mont MA, Rajadhyaksha AD, Hungerford DS. Outcomes of limited femoral resurfacing arthroplasty compared with total hip arthroplasty for osteonecrosis of the femoral head. J Arthroplasty (Suppl 1) 2001; 16(8):134-9.

 PubMedGoogle Scholar

Moroni A, Savarino L, Cadossi M, Baldini N, Giannini S. Does ion release differ between hip resurfacing and metal-on-metal THA. Clin Orthop 2008; 466(3):700-7.

 PubMed Web of Science ®Google Scholar

Patel R, Stygall J, Harringtom J, Newman S, Haddad F. Intra-operative cerebral microembolisation during primary hybrid total hip arthroplasty compared with primary hip resurfacing. Acta Orthop Belg 2009; 75(5):671-7.

 PubMedGoogle Scholar

Pattyn C, De Smet KA. Primary ceramic-on-ceramic total hip replacement versus metal-on-metal hip resurfacing in young active patients. Orthopedics 2008; 31(1):1078.

 PubMedGoogle Scholar

Ritter MA, Gioe TJ. Conventional versus resurfacing total hip arthroplasty. A long-term prospective study of concomitant bilateral implantation of prostheses. J Bone Joint Surg (Am) 1986; 68(2):216-25.

 PubMedGoogle Scholar

Robb C, Harris R, O'Dwyer K, Aslam N. Radiographic assessment of biomechanical parameters following hip resurfacing and cemented total hip arthroplasty. Hip Int 2009; 19(3):251-6.

 PubMedGoogle Scholar

Silva M, Lee KH, Heisel C, DeLa Rosa MA, Schmalzried TP. The biomechanical results of total hip resurfacing arthroplasty. J Bone Joint Surg (Am) 2004; 86(1):40-6.

 PubMedGoogle Scholar

Stulberg BN, Fitts SM, Bowen AR, Zadzilka JD. Early return to function after hip resurfacing. Is it better than contemporary total hip arthroplasty? J Arthroplasty 2009: In Press.

 Google Scholar

Wagner M, Wagner H. Preliminary results of uncemented metal on metal stemmed and resurfacing hip replacement arthroplasty. Clin Orthop (Suppl) 1996; (329): S78-S88.

 PubMedGoogle Scholar

Witzleb W-C, Ziegler J, Krummenauer F, Neumeister V, Guenther K-P. Exposure to chromium, cobalt and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. Acta Orthop 2006; 77(5):697-705.

 PubMed Web of Science ®Google Scholar

Zywiel MG, Marker DR, McGarth MS, Delanois RE, Mont MA. Resurfacing matched to standard total hip arthroplasty by preoperative activity levels. A comparison of postoperative outcomes. Bull NYU Hosp Joint Dis 2009; 67(2):116-9.

 PubMedGoogle Scholar