Hip Resurfacing
DESCRIPTION
Hip resurfacing is a bone-preserving procedure that helps restore comfort and function to individuals’ hips damaged by degenerative joint disease (osteoarthritis, rheumatoid arthritis, and traumatic arthritis), avascular necrosis, or developmental hip dysplasia. It can be categorized as a partial resurfacing or total hip resurfacing and is performed as an alternative to total hip arthroplasty, particularly in young active individuals who would potentially outlive the hip prosthesis.
Total hip resurfacing involve placing, porous metal cup into the acetabulum (hip socket) and cementing a metal cap onto the femoral head. This results in an articulating, metal-on-metal surface. In a partial resurfacing procedure, a small disc is placed over the damaged area of the femur head. The socket or acetabulum is not touched at all. Individuals with extensive damage to the femur may not be candidates for resurfacing procedures because the femoral head may be too damaged to hold the resurfacing component.
Advantages of resurfacing compared to arthroplasty include preservation of the femoral neck and femoral canal; thus facilitating revision or conversion in the future to a total hip replacement. Hip resurfacing is often viewed as a postponement procedure to delay the need for total hip arthroplasty. The resurfaced head more closely resembles the anatomic size of the femoral head and is therefore more stable and less prone to dislocation when compared to the total hip arthroplasty.
Hip resurfacing has undergone various evolutions over the past several decades. Modifications in prosthetic design, composition and implantation techniques have occurred. Early iterations of the device were composed of ceramic and polyethylene however metal components have since been designed to improve implant longevity.
A variety of devices have been cleared by the FDA for hip resurfacing (total and partial) under the FDA’s 510(k) mechanism. The FDA summary of approval lists indications and contraindications for each device. (See additional information section)
POLICY
Metal on metal total hip resurfacing used as an alternative to total hip replacement is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Partial hip resurfacing in individuals with osteonecrosis of the femoral head is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
All other types and applications of hip resurfacing are considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise its use will be considered investigational.
Policies with similar titles: Shoulder Resurfacing
MEDICAL APPROPRIATENESS
Hip resurfacing is medically appropriate if ANY ONE of the following:
Total hip resurfacing used as an alternative to total hip replacement if ALL of the following criteria are met:
1 or more of the following criteria:
Treatment of degenerative joint disease is needed as indicated by ALL of the following:
Presence of significant radiographic findings (eg, hip joint destruction, severe narrowing, bone deformities, osteonecrosis)
Optimal medical management has been tried and failed
Treatment is needed because of 1 or more of the following:
Disabling pain
Functional disability
Osteonecrosis of femoral head
Individual is likely to outlive a traditional prosthesis
Partial hip resurfacing for osteonecrosis of the femoral head if ALL of the following:
A candidate for total hip replacement if ALL of the following criteria are met:
Radiographic evidence of osteonecrosis
Failure of optimal medical management
Treatment needed because of 1 or more of the following:
Disabling pain
Functional disability
Failure of or not a candidate for more conservative measures
Individual is likely to outlive a traditional prosthesis
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
The FDA listed several contraindications for hip resurfacing. These contraindications include (not a complete listing) the following items:
Bone stock inadequate to support the device due to:
Severe osteopenia or a family history of severe osteoporosis or severe osteopenia
Osteonecrosis or avascular necrosis with more than 50% involvement of the femoral head
Multiple cysts of the femoral head (more than 1 cm)
Skeletal immaturity
Vascular insufficiency, muscular atrophy, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery
Known moderate to severe renal insufficiency
Severely overweight
Immunosuppressed or receiving high doses of corticosteroids
In addition total hip resurfacing (metal on metal) is also contraindicated in the following circumstances:
Known or suspected metal sensitivity
Females of child bearing age due to unknown effects on the fetus of metal ion release
The FDA lists the following indication for partial hip resurfacing: pathology affects the femoral head with adequate bone stock to support the device (i.e. less than 50 % of femoral head involved in the pathology) with an acetabular cavity that is normal; free of deformities or weakness (i.e. minimal change in acetabular cartilage and articular cartilage space)
The evidence available at this time supports the conclusions that hip resurfacing (partial or total) presents an effective alternative for active patients who are considered too young for total hip replacement, when performed by surgeons experienced in the technique. The literature on risk factors for metallosis and implant failure is evolving as longer follow-up becomes available.
There is minimal published medical literature regarding total hip resurfacing using polyethylene components.
SOURCES
Agency for Healthcare Research and Quality. (2006, December). Horizon scan on hip replacement surgery. Retrieved March 22, 2011 from http://www.ahrq.gov.
Amanatullah, D., Cheung, Y., & Cesare, P. (2010). Hip resurfacing arthroplasty: a review of the evidence for surgical technique, outcome, and complications. Orthopedic Clinics of North America, 41 (2) 263-272.
Amstutz, H., & LeDuff, M. (2009) Hip resurfacing results for osteonecrosis are as good as for other etiologies at 2 to 12 years. Clinical Orthopaedics and Related Research, 468 (2), 375-381. (Level 3 evidence - Industry sponsored)
BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2009). Hip resurfacing (7.01.80). Retrieved March 14, 2011 from BlueWeb.
Corten K., & MacDonald, S. (2010). Hip resurfacing data from national joint registries. Clinical Orthopaedics and Related Research, 468 (2), 351-357.
ECRI Institute. Health Technology Information Service. Emerging Technology (TARGET) Evidence Report. (2011, March). Metal on metal total hip resurfacing for degenerative hip disease. Retrieved March 18, 2011 from ECRI Institute. (28 articles and/or guidelines reviewed)
Grecula, M. (2005).Resurfacing arthroplasty in osteonecrosis of the hip. Orthopedic Clinics of North America, 36 (2), 234-242.
National Institute for Clinical Excellence. (2005, February) Guidance for the use of metal on metal hip resurfacing arthroplasty. Retrieved March 22. 2011 from http://www.nice.org.uk/nicemedia/live/11462/32395/32395.pdf.
Stulberg, b., Fitts, S., Zadzilka, J., & Trier, K. (2009). Resurfacing arthroplasty for patients with osteonecrosis. Bulletin of the NYU Hospital for Joint Diseases, 67 (2) 138-141.
Technology Evaluation Center. (2007, May). Metal-on-metal hip resurfacing. (Vol. 22, No. 3). Retrieved July 11, 2007 from http://www.bcbs.com/blueresources/tec/vols/22/22_03.pdf. (37 articles and/or guidelines reviewed)
U. S. Food and Drug Administration. (2006, May). Center for Devices and Radiological Health. Premarket Notification Database. K050016b: Cormet hip resurfacing system. Retrieved March 21, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf5/P050016b.pdf.
U. S. Food and Drug Administration. (2006, May). Center for Devices and Radiological Health. Premarket Notification Database. K062960: CONSERVE® Femoral Resurfacing Component. Retrieved March 22, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf6/K062960.pdf.
U. S. Food and Drug Administration. (2007, July). Center for Devices and Radiological Health. Premarket Notification Database. K040033a Birmingham hip resurfacing (BHR) system. Retrieved March 21, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf4/p040033a.pdf.
Winifred S.Hayes, Inc. Medical Technology Directory. (2006, July; last updated search June 28, 2010). Total Hip Resurfacing. Retrieved March 15, 2011 from www.Hayesinc.com/subscribers. (73 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 11/11/2006
MOST RECENT REVIEW DATE: 11/16/2011
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