BlueCross and BlueShield of Montana Medical Policy/Codes
Hip Resurfacing (HF)
Chapter: Surgery: Procedures
Current Effective Date: September 24, 2013
Original Effective Date: May 01, 2006
Publish Date: June 24, 2013
Revised Dates: September 1, 2007; October 25, 2010; October 7, 2011; June 11, 2012; June 24, 2013
Description

Hip resurfacing can be categorized as total hip resurfacing, consisting of an acetabular and femoral shell and partial hip resurfacing, in which a femoral shell is implanted over the femoral head.

Total Hip Resurfacing (THR)

THR has undergone various evolutions over the past several decades, with modifications in prosthetic design and composition and implantation techniques.  For example, similar to total hip prostheses, the acetabular components of total hip resurfacing have been composed of polyethylene.  However, over the years it became apparent that device failure was frequently related to the inflammatory osteolytic reaction to polyethylene debris wear particles.  Metal acetabular components have since been designed to improve implant longevity.  Wear particles from metal-on-metal chromium and cobalt implant components are also of potential concern.

Proposed advantages of THR compared to total hip arthroplasty (THA) include preservation of the femoral neck and femoral canal, thus facilitating revision or conversion to a total hip replacement, if required.  In addition, the resurfaced head is more similar in size to the normal femoral head, thus increasing the stability and decreasing the risk of dislocation compared to THA.  THR, investigated in a broader range of patients including those with osteoarthritis, rheumatoid arthritis, and advanced avascular necrosis, may be considered an alternative to total hip arthroplasty, particularly in young active patients who would potentially outlive a total hip prosthesis.  Therefore, THR could be viewed as a time-buying procedure to delay the need for a THA.  

The Buechel-Pappas Integrated Total Hip Replacement has received an FDA 510(k) clearance for use in THR.  The weight-bearing surfaces of this device are composed of a ceramic femoral component and a polyethylene acetabular component.  There has also been interest in metal on metal designs as a technique to reduce the debris wear particles.  The Conserve®Plus (Wright Medical Technology) is a metal-on-metal design that is currently undergoing investigation as part of the FDA approval process.  This trial will include 300 patients who will be followed up for a minimum of two years.  The Cormet® 2000 hemi-arthroplasty device has 510(k) marketing clearance from the FDA.  In May 2006, the FDA granted Pre-Market Approval (PMA) to the Birmingham Hip Resurfacing (BHR) system for use in patients requiring primary hip resurfacing arthroplasty for non-inflammatory or inflammatory arthritis.

Partial Hip Resurfacing (PHR)

Partial hip resurfacing is considered a treatment option for avascular necrosis with collapse of the femoral head and preservation of the acetabular.  A variety of devices have been cleared by the FDA for partial hip resurfacing under the FDA’s 510(k) mechanism.

In a PHR procedure, a small cobalt-chrome disc is placed over the damaged area of the femur head.  The socket or acetabulum is not touched at all.  Preservation of bone is especially attractive for young, active patients who are likely to outlive their first hip replacement operation and will most likely need to have another replacement operation during their lifetime.  Not everyone is a candidate for resurfacing; the femoral head may be too damaged to hold the resurfacing component.  It is important that the patient does not have any risk factors that may increase the risk of failure of the partial surface hip replacement operation.

Unlike a total hip replacement, PHR leaves more bone in place and does not require that the femur neck shaft be removed. During the procedure, usually only the femoral head is reshaped and resurfaced with an artificial shell to help reduce pain and ensure joint stability. The chance of subsequent hip dislocation is also lower in this surgery than in a total hip replacement.

Policy

Prior authorization is recommended. To authorize, call Blue Cross and Blue Shield of Montana (BCBSMT) Customer Service at 1-800-447-7828 or fax your request to the Medical Review Department at 406-441-4624. A retrospective review is performed if services are not prior authorized.

Medically Necessary

BCBSMT may consider metal-on-metal total hip resurfacing with an U. S. Food and Drug Administration (FDA) approved device system medically necessary as an alternative to total hip arthroplasty (THA) for patients meeting ALL the following criteria:

  • Diagnosis of degenerative joint disease (e.g., osteoarthritis, rheumatoid arthritis, traumatic arthritis, dysplasia, or avascular necrosis; involving less than 50% of the femoral head), AND
  • Patient is unsuitable for traditional THA because of increased activity level, OR is of younger age (less than 55 years of age) because of increased possibility of requiring future ipsilateral hip joint revision, AND
  • Procedure performed by a surgeon who has received appropriate training in the total hip resurfacing technique, AND
  • Does not have one or more of the following FDA listed contraindications for total hip resurfacing:
    1. Osteonecrosis or avascular necrosis with more than 50% involvement of the femoral head,
    2. Multiple cysts of the femoral head (more than 1 cm),
    3. Infection of the body or blood,
    4. Skeletal immaturity,
    5. Conditions that will prevent the artificial hip joint system from remaining stable (muscular atrophy or neuromuscular disease),
    6. Conditions that may prevent following instructions during the recovery period,
    7. Osteoporosis or family history of severe bone loss,
    8. Women of childbearing age.  It is unknown whether metal ions released by the device could harm an unborn child,
    9. Moderate to severe renal insufficiency
    10. Metal sensitivity (reaction to wearing metal jewelry),
    11. Immunosuppressed due to diseases such as AIDS or are receiving high doses of corticosteroids, or
    12. Severely overweight (body mass index (BMI) equal to or greater than 40 kg/meter squared).

Partial hip resurfacing (PHR) with an FDA approved device may be considered medically necessary in patients with osteonecrosis of the femoral head who have one or more contraindications for metal-on-metal implants and meet all the following criteria:

  • The patient is a candidate for total hip replacement; AND
  • Is likely to outlive a traditional prosthesis; AND
  • The patient has known or suspected metal sensitivity or concern about potential effects of metal ions; AND
  • There is no more than 50% involvement of the femoral head; AND
  • There is minimal change in acetabular cartilage or articular cartilage space identified on radiography.

Investigational

BCBSMT considers all other types and applications of hip resurfacing experimental, investigational and unproven.

Rationale for Benefit Administration

This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. Blue Cross and Blue Shield of Montana recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.

When using this policy to determine whether a service, supply or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.

Rationale

Studies demonstrate that metal-on-metal THR is an acceptable alternative to total hip replacement in younger patients where bone conservation is a consideration in preparation for later THA.

According to the FDA summary of safety and effectiveness, the Birmingham device was implanted in 2,385 hips by a single investigator between July 1997 and May 2004 in Birmingham, England.  Of the 2,385 cases, 27 revisions were required including ten revisions due to femoral neck fracture, six for femoral head collapse, one for dislocation, two for avascular necrosis, and eight for infections.  In addition, the FDA considered less complete data on 3,374 BHR cases performed by 140 surgeons worldwide (currently 22 countries approve marketing of the BHR device).  All of the available data on the BHR was reported to the Oswestry Outcomes Centre; these 5,000 cases are referred to as the Oswestry Worldwide Cohort.  Although, there continues to be no randomized, controlled clinical trial comparing hip resurfacing to hip arthroplasty there is good evidence that for patients, due to their relatively younger age, may not be suitable candidates for traditional THA due to an increased possibility of requiring future ipsilateral hip joint revision.  Therefore, THS may be considered appropriate for patients age 55 and younger who are candidates for total hip replacement.  For all other patients, firm conclusions cannot be reached concerning the effect of total hip resurfacing on the health outcomes of the patient compared to conventional THA.

Treacy and colleagues reported the five-year survival of Birmingham hip resurfacing arthroplasty in 144 patients was 98% overall.  Failure of the femoral component occurred in three cases within the first two years of the study (two infections and one fracture).  Shimmin and Back reviewed 3497 Birmingham hip resurfacings performed by 89 surgeons between April 1999 and April 2004.  The authors reported the incidence of femoral neck fracture was 1.46% (50 of 3497) and the mean time to fracture was 15.4 weeks.  Glyn-Jones and colleagues evaluated the stability of Birmingham hip resurfacing arthroplasties by radiographic analysis in 22 hips in 20 patients.  At 24 months, migration of the head of the femoral component was not statistically significant (0.2 mm total three-dimensional).  Itayem et al. also evaluated stability in 20 Birmingham hip resurfacing arthroplasties with radiographic analysis and found no evidence of excessive early migration or femoral component loosening at 24 months.

Although early hip prostheses with a metal-on-metal bearing were displaced by metal-on-polyethylene prostheses with lower loosening rates in the early years of THA, the advantages of the metal-on-metal bearing have subsequently been recognized.  These advantages include very low wear with a commensurately low risk of osteolysis.  Metal-on-metal bearings do not fracture and favor larger diameters for greater range of motion and stability, thus extending the functional capacity of THA.  Information regarding exposure to metal ions can be drawn from first-generation devices, some of which continued to function well after 30 years, and 15-year follow-up data with initial second-generation devices.  Metal-on-metal bearings should be avoided in patients with existing or potential renal impairment.  Hypersensitivity to the implanted metal can rarely occur.  Theoretic concerns regarding organ toxicity and carcinogenesis have been assuaged by the absence of documented adverse outcomes.  The aggregate data demonstrate a favorable benefit-to-risk ratio and the potential that metal-on-metal articulations can expand the functional capacity of THA and increase the population of individuals who are acceptable candidates for this new technology.

2009 Update

A BCBSA Technology Evaluation Center (TEC) Assessment reviewed evidence published through January 2007 on metal-on-metal total hip resurfacing.  The assessment evaluated studies of individuals with advanced degenerative joint disease of the hip who received a HR device and that reported data on short- and long-term clinical outcomes, including benefits and harms, as an alternative to THA.  TEC identified one randomized controlled trial, and 12 uncontrolled series.  For the assessment, these published trials, the FDA PMA submission data, and information from the Australian Orthopedic Association (AOA) National Joint Replacement Registry were evaluated.

In the randomized controlled trial (100 patients in each group), the HR device was implanted in patients who were younger (49 to 51 years old) and had a smaller body mass index (17 to 49 kg/m2) than those who usually undergo THA (>65 years old), and the majority comprised male patients (63% to 68%) who were being treated for advanced osteoarthritis (75%).  In comparison to THA, the perioperative differences demonstrate that HR reduced the surgical time (p<0.001), decreased the hospital stay (5 vs. 6.1 days), and used a longer incision (p<0.001).  Both groups had a similar incidence of complications; with two deep vein thromboses per group, and two THA patients had deep infections without recurrence.  At 12-month follow-up, two patients in the THA group required revision for femoral head aseptic loosening at six and nine months, respectively, and none experienced femoral head fracture.  Both groups showed substantial improvement over preoperative status on functional outcomes measures and reported satisfaction or very high satisfaction scores (98%).

The twelve published series reporting clinical outcomes after HR included a total of 2,076 patients (71% male) who ranged in mean age from 34 to 57 years.  Although most patients had advanced osteoarthritis (80%), some studies enrolled patients with femoral head osteonecrosis and/or developmental hip dysplasia, and only three used the FDA-approved Birmingham device. Mean follow-up was approximately three years, but ranged from less than a year to twelve years, and the proportion of enrolled patients available at follow-up was generally 90% to 100%, but as low as 22%.  Of the 2,076 patients treated with HR, 57 (2.7%) required revision to THA, most for femoral neck fracture or component loosening; the proportion of cases that required revision ranged from 0.3% to 22%.

Although the 12 published series exhibit little consistency in outcomes measures used, the aggregate data suggest that HR-treated patients who do not require a revision have substantial symptomatic improvement of pain and hip function over presurgical status.  Moreover, HR patients report substantial activity levels and returning to playing sports after treatment.

The TEC Assessment also evaluated the patient safety and effectiveness data considered for the FDA submission of the Birmingham device from the McMinn Cohort, which are supported by unpublished data on 3,374 hips implanted by 140 surgeons and published reports on more than 3,800 hips treated by multiple surgeons (Worldwide Cohort).

The McMinn Cohort included 71% men and 29% women, ranging in age from 13 to 86 years (average, 53 years).  The predominant diagnoses for treatment were advanced osteoarthritis (75%), dysplasia (16%), avascular necrosis (4%), inflammatory arthritis (2%), and “other” (3%).  The Worldwide Cohort was reportably comparable.  At the five-year follow-up, a total of 76 revisions to THA were reported (2.26%), resulting from events similar to those reported for the McMinn Cohort.  In addition, results of the Oswestry-Modified Hip Scores for both cohorts showed improvement at five years from a baseline mean of 60.1 to 94.8 (58%).  With regard to long-term safety, literature summaries provided to the FDA demonstrated increased serum and urinary concentrations of metal ions postoperatively in patients with THA, particularly after metal-on-metal procedures, but data show no conclusive evidence of significant detrimental effects.

The Australian Orthopedic Association registry’s annual report for 2006 is based on 92,210 THAs, including 84,872 primary THAs, 7,205 metal-on-metal HRs, and 133 thrust-plate procedures.  Some of these data may include patients reported in the Worldwide Cohort.  In general, resurfacing procedures were used more often in men than in women (73% vs. 56%) and in younger patients (90% <65 years) than primary THA.  At the five-year follow-up, conventional THAs showed fewer revisions (1.7%) than HRs (2.2%), but THA prostheses may not be reflected, and no patient demographic characteristics were available for comparison.

TEC concluded that use of the FDA-approved metal-on-metal HR devices meets the TEC criteria as an alternative to THA in patients who are candidates for THA and who are likely to outlive a traditional prosthesis.  A substantial body of evidence shows that total hip resurfacing is associated with consistent and strong symptomatic and functional improvements comparable to those obtained with current total hip arthroplasty in patients less than 65 years old.  Total hip resurfacing differs procedurally from arthroplasty in conserving a patient’s native femoral bone stock; this difference is important should subsequent revision surgery be required.  The available evidence shows that HRs short-term symptomatic and functional health benefits are at least as good as those of THA over midterm follow-up, with no substantial differences in revision rates, among patients younger than 65 years who are likely to outlive a traditional prosthesis.  Also, inference from the available long-term evidence suggests that HR will be at least as beneficial as THA in patients who are likely to outlive a traditional prosthesis, based on 1) appropriate patient selection, 2) the fact that HR is a bone-conserving procedure that preserves the femoral head and stock largely intact, and 3) substantial 5-year follow-up of device survival.

Mont et al. described the results of the FDA-approved Investigational Device Exemption (IDE) prospective, multicenter trial of the Conserve Plus hip resurfacing system.  The investigators identified a number of risk factors for complications after the first 292 procedures; these included the presence of cysts, poor bone quality, leaving reamed bone uncovered, minimizing the size of the femoral component to conserve acetabular bone, and malpositioning of the acetabular shell.  Modification of inclusion criteria and surgical technique in the next 906 patients (1,016 hips) resulted in a decreased rate of femoral neck fracture (from 7% to <1%).  There was also a trend toward reduction in other types of complications (e.g., nerve palsy was reduced from 4.1% to 2.2% and loosening of the acetabular cup from 3.4% to 1.9%).  No differences between the two cohorts were observed in the Harris hip score (93 vs. 93) or the SF-12 (e.g., physical component score of 50 vs. 50).  Another study compared gait analysis in 15 patients following successful HR with 15 patients who had a successful THA using a small femoral head, and with ten patients who had osteoarthritis and 30 age- and sex-matched controls from a normative database.  Walking speed (1.3 m/s) was found to be faster in the HR group than in the THA (1.0 m/s) or osteoarthritis groups (1.0 m/s).  Measurement of abductor and extension movements found that the gait of patients following HR was closer to normal than the gait of patients who had undergone THA.

It is thought that revision of HR to THA might have better outcomes than THA to revision, but little data support this assumption.  One recent study compared outcomes in 20 patients (from a group of 844 primary HRs performed between 1997 and 2005) requiring conversion surgery for failed HR (five femoral neck fractures and 16 with femoral component loosening) with outcomes in 58 patients of similar age (64 hips from patients <65 years old) who had been treated with a primary THA by the same surgeon during the same period.  The acetabular component was retained in 18 hips (and revised in three because the matching femoral head was not available at the time of surgery).  The study found no significant difference in operative time between conversion (178 minutes, range of 140 to 255) and primary THA (169 minutes, range of 110 to 265), or in complication rates between the two groups (14% vs. 9%, respectively).  At one to nine years’ follow-up (average of 46 months for the HR-THA revision group and 57 months for the primary THA group) outcomes as measured by the UCLA, SF-12, and Harris hip scores were similar (e.g., Harris hip score of 92 for the revision group and 90 for the primary THA control group).  Although this small study suggests that a resurfaced femoral component might be converted to THA without additional complication, larger comparative studies between HR-THA and THA-THA revisions are needed.  As noted previously, long-term health outcomes (pain, function, and implant survival) following HR are not yet known.

There is minimal published medical literature regarding total hip resurfacing using polyethylene components.

A search of peer reviewed literature through May 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy. 

2010 Update:

An updated search of the MEDLINE database through March 2010 identified two qualitative systematic reviews, two randomized controlled trials comparing THR with large-diameter head THA and other publications concerning factors in survival such as patient selection criteria and the surgeon’s learning curve.

One of the systematic reviews compared outcomes from THR and THA in studies with short- to mid-term follow-up.  The seven comparative studies that assessed return to sports and activity showed either similar outcomes for the two procedures or advantages for the THR group. Three additional studies assessed gait, and one study was identified that assessed postural balance; all four showed similar or better outcomes for THR than THA.  Two studies were discussed that compared the outcomes of conversion of failed THR to THA with primary THA.  One of the two studies was reviewed above.  The second was a 2009 report that compared outcomes of 39 patients whose resurfacing was converted to THA with a group of primary THA patients that had been matched by gender, age, body mass index (BMI), and pre-operative Harris hip score; all procedures had been performed by the same surgeon.  Perioperative measures were similar except for the mean operating time, which was 19 minutes longer for the revision group.  At an average 45 months follow-up, the mean Harris hip scores were similar for the two groups (score of 92 for conversion to THA and 94 for primary THA).

In 2008, Queseda, Marker and Mont published a qualitative systematic review that focused on advantages and disadvantages of THR in comparison with THA.  Advantages were reported to include possible bone conservation on the femoral side, lower dislocation rates, more range-of-motion, more normal gait pattern, increased activity levels, increased ease of insertion with proximal femoral deformities or retained hardware, and straightforward revision.  Possible disadvantages of resurfacing were reported to be increased difficulty to perform the procedure, increased acetabular bone stock loss, femoral neck fractures, and the effects of metal ions. Although prospective controlled studies with long- term follow-up are needed for conclusive evaluation of these issues, the literature reviewed by these investigators suggests an increased risk of femoral neck fractures in post-menopausal women and small-boned men.  Queseda et al. conclude that THR is most appropriate in young (less than 60 years) active men.

For a 2009 report on patient selection criteria for THR, Nunley and colleagues reviewed 207 publications, the majority of which they found to have little or no description of the patient population, small sample sizes, poor study design, limited control of bias, and inadequate statistical analysis.  The literature showed no clear consensus on the upper age limit for male patients, but the most commonly used criteria was age younger than 65 years.  Nine articles suggested that female patients should be cautiously evaluated before performing HR, especially if they are postmenopausal or have decreased bone mineral density.  Some of the data reviewed was from the Australian joint replacement registry, where women 65 or older were observed to have a revision rate of 11% at four years.  This was compared with men younger than 55 years of age who had a revision rate of less than 2%.  Both of these cohorts (older women and younger men) have revision rates of 2% after THA.  The evidence reviewed by Nunley et al. also indicates that obesity, defined as BMI > 35 kg/m²can be viewed as a relative contraindication to THR, but not THA.  Femoral head cysts, head-neck junction abnormalities, and poor bone density may also be considered risk factors for implant failure.  The literature on metal sensitivity and the presence of aseptic lymphocytic vasculitis-associated lesions (ALVAL) is evolving, and the potential for transplacental transfer of metal ions is a concern for young female patients who have the potential to become pregnant in the future.  The authors concluded that the best candidates for hip resurfacing are men under age 65 with osteoarthritis and relatively normal bony morphology.

Two randomized controlled trials were published in 2009 that randomized patients to THR or THA with a large diameter metal-on-metal implant.  The study by Lavigne et al. tested the hypothesis that the observed improvement in activity with THR is due either to patient selection bias or to the larger femoral head with THR.  In order to test this hypothesis, 48 patients were randomized to either THR or large-head THA.  The patients and the evaluators at the gait laboratory were kept blinded to the type of arthroplasty until one year after surgery.  There were no differences between the two groups for the majority of measures at 3, 6, and 12 months after surgery.  Specifically, similar results were observed for normal and fast walking, postural evaluations, timed-up and go-test, hop test, hip flexor and abductor strength ratio.  The THR group performed better during the functional reach test, and the THA group completed the step test three seconds faster than the THR group.  The WOMAC, SF-36, Merle d’Aubigne, and UCLA activity scores were similar in the two groups.  Garbuz and colleagues randomized 107 patients to THR or large-head metal-on-metal THA.  There was no difference in WOMAC or SF-36 scores for the 73 patients who had been followed for at least one year.  However, for the subset of patients who had been tested for serum levels of cobalt and chromium, cobalt was 10-fold higher and chromium was 2.6 fold higher in the large head metal-on-metal THA group than the THR group.  This was a 46-fold increase from baseline in serum cobalt and a 10-fold increase from baseline in serum chromium for the large-diameter head THA group, possibly related to particulate wear at the head-neck junction.  Both of these studies support the hypothesis that the improved activity observed in THR patients is due to the larger diameter components used in resurfacing.

The increase in serum cobalt and chromium ions with metal-on-metal THR remains a concern.  One retrospective study of 610 consecutive hip resurfacings (120 with more than five-year follow-up) reported that failure was possibly related to metal debris on 0.5% of THRs.  However, after examining histological samples taken at the time of revision, Olivere and colleagues concluded that the rate of metallosis-related revision in their series of 463 consecutive patients was 3% at five years.  All of the patients in this series had been recruited into the local arthroplasty follow-up program at the time of the primary surgery; 437 (94%) returned for clinical and radiological follow-up with a mean follow-up of 43 months (range, 6-90 months).  Case notes, radiographs, and magnetic resonance scans were available for the 13 revisions (2.8%, 12 patients).  Histological findings were available for 12 cases, and were re-reviewed by a histopathologist with experience in metal wear and debris.  In seven cases, the histological findings were consistent with a response to metal wear debris.  Survivorship analysis gave an overall survival rate of 95.8% at five years, with an end-point survival of 96.9% at five years for metallosis requiring revision.  The relative risk for female gender in the metallosis group was 4.94.  Also associated with metallosis were a smaller femoral component, greater abduction angle, and a higher BMI.

Other studies suggest a high learning curve for THR related to the increased difficulty in accessing the acetabular compartment.  For example, in one study most of the failures were related to early acetabular loosening.  A report by Nunley et al. suggests that for experienced hip surgeons the learning curve for avoiding early complications (e.g., early femoral fracture) is 25 cases or less, but the learning curve for achieving the desired component positioning is 75-100 cases or more.  Steeply inclined component positioning along with a small size of component have been shown to be associated with metal ion levels, possibly due to an increase in edge loading.

Partial Hip Resurfacing for Osteonecrosis

A search of the literature on resurfacing for osteonecrosis identified a number of articles, including a 2005 review and a 2009 study on the topic.  Both articles discussed comparisons of hemi-resurfacing to THR, referencing a single comparative study by Beaule from 2004; thus, it is unlikely that additional comparative resurfacing studies have been published since 2004.  This literature shows total resurfacing/replacement to provide more consistent and better initial pain relief than partial resurfacing.  The increase in poor outcomes with resurfacing is believed to be related to continued abrasion and possible misfit of the femoral component against the native acetabular cartilage.  Therefore, for osteonecrosis in younger patients who do not have contraindications for the metal-on-metal prosthesis, total hip resurfacing (femoral and acetabular implant) would be preferred over a femoral component alone.

Summary

The evidence available at this time supports the conclusions reached above that HR (partial or total) presents an effective alternative for active patients who are considered too young for THA, 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.  Emerging evidence indicates an increased risk of failure in women due to decreased bone strength and increased risk of metal sensitivity.  Therefore, these risk factors should be considered in the overall patient evaluation for total hip replacement.

2011 Update

A search of peer reviewed literature was conducted through May 2011.  In 2010, Amstutz et al. reported 12-year follow-up (range, 10.8 to 12.9 years) from the first 100 hip resurfacings at their institution.  The 89 patients in this series were followed annually with radiographs, range of motion, and questionnaires.  Two patients were lost to follow-up and five patients died during the follow-up period of causes unrelated to the surgery.  Eleven hips had conversion to total hip arthroplasty.  Kaplan-Meier survivorship of the resurfacing implant was 93.9% at five years and 88.5% at 10 years.  Subgrouping by femoral component size showed 10-year survival of 95.6% for a component size of >46 mm, 83.8% for a component sizes of 44 or 46 mm, and 78.9% for a component size of < 42 mm.  Multivariate analysis showed that low body-mass index, small femoral component size, and large defects in the femoral head were risk factors for failure.  High scores for activity level were not associated with an increased risk of revision.

In 2010, de Steiger et al. reported outcomes of revised THR from the Australian Joint Replacement Registry.  A total of 437 revisions were reported (out of 12,093 primary THR, approximately 4%) between 1999 and 2008.  After excluding 39 cases of revision for infection, the major reason for revision of primary THR was fracture of the femoral neck (43%), followed by loosening/lysis (32%), metal sensitivity (7%), and pain (6%).  A femoral-only revision, which converts the joint to a conventional total hip replacement, was performed in 247 of the 397 revisions (62%) undertaken for reasons other than infection.  At three years, the rate of re-revised THR-THA was 7%, compared with 2.8% of primary conventional THA.  Reasons for re-revision included loosening/lysis (n=6), infection (n=4), dislocation of prosthesis (n=1) and fracture (n=2).  At 5 years, femoral-only re-revision (7%) was similar to re-revision of both the acetabular and femoral components (5%), but the rate of acetabular-only re-revision was 20%.  A more relevant outcome for this policy, one that the investigators did not assess, would be a comparison of the re-revision rate of THR-THA versus THA-THA revisions.

Coding

Disclaimer for coding information on Medical Policies         

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

00.75, 00.85, 00.86, 00.87, 715.05, 715.15, 715.25, 715.35, 715.85, 715.95, 733.42

ICD-10 Codes
M16.10-M16.9, M87.051-M87.059, 0SUA0BZ, 0SUE0BZ, 0SUR0BZ, 0SUS0BZ
Procedural Codes: 27299, S2118
References
  1. Glyn-Jones, S., Gill, H.S., et al.  Roentgen stereophotogrammetric analysis of the Birmingham hip resurfacing arthroplasty. A two-year study. Journal of Bone and Joint Surgery Britain (2004) 86(2):172-6.
  2. Beaulé PE, Amstutz HC, Le Duff M et al. Surface arthroplasty for osteonecrosis of the hip: hemiresurfacing versus metal-on-metal hybrid resurfacing. J Arthroplasty 2004; 19(8 Suppl 3):54-8.
  3. Grecula MJ. Resurfacing arthroplasty in osteonecrosis of the hip. Orthop Clin North Am 2005; 36(2):231-42.
  4. Itayem, R., Arndt, A. et al.  Stability of the Birmingham hip resurfacing arthroplasty at two years; a radiostereophotogrammetric analysis study. Journal of Bone and Joint Surgery Britain (2005) 87(2):158-62.
  5. De Smet, K.A.  Belgium experience with metal-on-metal surface arthroplasty.  Orthopedic Clinics of North America  (2005) 36(2):203-13.
  6. Treacy, R.B., McBryde, C.W., et al.  Birmingham hip resurfacing arthroplasty. A minimum follow-up of five years.  Journal of Bone and Joint Surgery Britian (2005) 87(2):167-70.
  7. Shimmin, A.J., Back, D.  Femoral neck fractures following Birmingham hip resurfacing: a national review of 50 cases. Journal of Bone and Joint Surgery Britain 2005; 87(4):463-4.
  8. Vendittoli, P.A., Lavigne M., et al.  A prospective randomized clinical trial comparing metal-on-metal total hip arthroplasty and metal-on-metal total hip resurfacing in patients less than 65 years old.  Hip International (2006) 16(2):S73-81.
  9. Pollard, T.C., Baker, R. P., et al.  Treatment of the young active patient with osteoarthritis of the hip.  A five-to seven-year comparison of hybrid total hip arthroplasty and metal-on-metal resurfacing.  Journal of Bone and Joint Surgery Britain (2006) 88(5):592-600.
  10. U.S. Food and Drug Administration, Department of Heath and Human Services, Birmingham Hip Resurfacing (BHR) System.  (2006 May 9). 
  11. U. S. Food and Drug Administration (FDA).  Center for Devices and Radiological Health (CDRH). CDRH Consumer Information.  New Device Approval. Birmingham Hip Resurfacing (BHR) System – P040033. May 9, 2006.
  12. Mont MA, Seyler TM, Ulrich SD et al. Effect of changing indications and techniques on total hip resurfacing. Clin Orthop Relat Res 2007; 465:63-70.
  13. Mont MA, Seyler TM, Ragland PS et al. Gait analysis of patients with resurfacing hip arthroplasty compared with hip osteoarthritis and standard total hip arthroplasty. J Arthroplasty 2007; 22(1):100-8.
  14. Ball ST, Le Duff MJ, Amstutz HC. Early results of conversion of a failed femoral component in hip resurfacing arthroplasty. J Bone Joint Surg Am 2007; 89(4):735-41.
  15. Quesada MJ, Marker DR, Mont MA. Metal-on-metal hip resurfacing: advantages and disadvantages. J Arthroplasty 2008; 23(7 Suppl):69-73.
  16. De Haan R, Pattyn C, Gill HS et al. Correlation between inclination of the acetabular component and metal ion levels in metal-on-metal hip resurfacing replacement. J Bone Joint Surg Br 2008; 90(10):1291-7.
  17. Kim PR, Beaulé PE, Laflamme GY et al. Causes of early failure in a multicenter clinical trial of hip resurfacing. J Arthroplasty 2008; 23(6 Suppl 1):44-9.
  18. Steffen RT, Pandit HP, Palan J et al. The five-year results of the Birmingham Hip Resurfacing arthroplasty: an independent series. J Bone Joint Surg Br 2008; 90(4):436-41.
  19. Marker DR, Strimbu K, McGrath MS et al. Resurfacing versus conventional total hip arthroplasty - review of comparative clinical and basic science studies. Bull NYU Hosp Jt Dis 2009; 67(2):120-7.
  20. McGrath MS, Marker DR, Seyler TM et al. Surface replacement is comparable to primary total hip arthroplasty. Clin Orthop Relat Res 2009; 467(1):94-100.
  21. Nunley RM, Della Valle CJ, Barrack RL. Is patient selection important for hip resurfacing? Clin Orthop Relat Res 2009; 467(1):56-65.
  22. Lavigne M, Therrien M, Nantel J et al. The John Charnley award: the functional outcome of hip resurfacing and large-head THA is the same: a randomized, double-blind study. Clin Orthop Relat Res 2009 Jun 20.
  23. Garbuz DS, Tanzer M, Greidanus NV et al. The John Charnley award: metal-on-metal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty: a randomized clinical trial. Clin Orthop Relat Res 2009 Aug 21.
  24. Ollivere B, Darrah C, Barker T et al. Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis. J Bone Joint Surg Br 2009; 91(8):1025-30.
  25. Nunley RM, Zhu J, Brooks PJ et al. The learning curve for adopting hip resurfacing among hip specialists. Clin Orthop Relat Res 2009 Sep 25 [Epub ahead of print].
  26. Stulberg BN, Fitts SM, Zadzilka JD et al. Resurfacing arthroplasty for patients with osteonecrosis. Bull NYU Hosp Jt Dis 2009; 67(2):138-41.
  27. Amstutz HC, Le Duff MJ, Campbell PA et al. Clinical and radiographic results of metal-on-metal hip resurfacing with a minimum ten-year follow-up. J Bone Joint Surg Am 2010; 92(16):2663-71.
  28. de Steiger RN, Miller LN, Prosser GH et al. Poor outcome of revised resurfacing hip arthroplasty. Acta Orthop 2010; 81(1):72-6.
  29. Metal-on-Metal Total Hip Resurfacing.  Chicago, Illinois:  Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (May 2011).
  30. Hip Resurfacing Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 May) Surgery 7.01.80.
History
October 2010 Added information on partial hip resurfacing; description and reference sections updated; added rationale section; title changed to "hip resurfacing"
October 2011 Updated policy references and reationale. Removed Not Medically Necessary statement, Investigational statement was already on the policy. No other changes.
June 2012 Policy updated with literature review through March 2012; 6 references added; policy statements unchanged
June 2013 Policy formatting and language revised.  Requirement of diagnosis of degenerative joint disease added to Medically Necessary statement.  Added contraindications to the FDA list that a patient must not have to be Medically Necessary.  Removed CPT codes 27130, 27134, 27137, and 27138.
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Hip Resurfacing (HF)