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Orthopaedics & Traumatology: Surgery & Research xxx (2020) xxx–xxx

Contents lists available at ScienceDirect

Orthopaedics & Traumatology: Surgery & Research

journal homepage: www.elsevier.com

Original article

Hip resurfacing generates a more physiological gait than total hip

replacement: A case-control study
Cedric Maillot a , Edouard Auvinet a , Ciara Harman b , Justin Cobb a , Charles Rivière a,b,∗
a
Laboratory Block, MSK Lab, Imperial college London, White City Campus, W12 0BZ London, United Kingdom
b
South West London Elective Orthopaedic Centre, Dorking road, KT18 7EG Epsom, United Kingdom

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

Article history: Background: Restoration of the constitutional joint anatomy after hip replacement favours physiological
Received 7 June 2019 peri-articular soft-tissue tension and kinematics, and is likely to be functionally beneficial. Hip resurfacing
Accepted 4 December 2019 (HR) and conventional total hip replacement (THR) are two different options for replacing degenerated
Available online xxx
hips, and are likely to result in different anatomical reconstruction. We initiated this study to investigate
the differences in gait performance between these two prosthetic options, and aimed to answer the
Keywords: following questions: (1) does HR result in better restoration of the frontal hip anatomical parameters,
Hip replacement
(2) and generate a more physiological gait compared to THR? (3) Does the quality of the anatomical
Hip resurfacing
Gait analysis
restoration after THR influence gait performance?
Symmetry index Hypotheses: Our hypothesis was that a better anatomical restoration using HR versus THR would produce
Kinematic alignment more physiological (symmetric) gait.
Methods: We retrospectively reviewed 52 patients who had unilateral primary osteoarthritis successfully
treated by replacement (40 THRs and 12 HRs). Hip anatomical parameters were measured on standing
pelvic radiographs on both the prosthetic and the contralateral healthy hips. Patients undertook gait
assessment under both normal and stress conditions at a mean follow-up of 14 months (7 to 16 months).
Gait performances were compared between HR and THR, and the relationship between gait performances
and quality of frontal anatomical restoration (estimated on radiograph) were assessed.
Results: Compared to the native contralateral side, the HR procedure tended to decrease all independent
anatomical radiographic parameters with the exception of the vertical centre of rotation offset, whilst
the THR procedure tended to increase them; the difference between HR and THR was only statistically
significant for femoral offset and global horizontal offset (increased after THR while reduced after HR).
Only 50% of THR and 25% of HR procedures closely anatomically (±15%) recreated both global horizontal
offset and global vertical offset. Under normal conditions (normal walking speed and flat ramp), the
gait was fairly symmetric for both the HR and the THR patients with a symmetry index of 0.62% and
3.14% respectively. At high walking speed (stress conditions), the symmetry index degraded for both
groups, but the gait remained more symmetric in the HR group (2.09%), compared to the THR group
(5.74%); nevertheless, the difference remained not statistically significant (p = 0.159). We were unable to
detect any significant relationship between gait performances and radiographically measured hip frontal
anatomical parameters.
Discussion/conclusions: HR procedure is more consistent than conventional THR in generating a more
physiological gait under stress conditions. Radiographic estimation of the quality of the frontal anatomical
hip restoration is of poor value to predict gait performances of THR patients.
Level of evidence: III – retrospective case-control study with prospective data collection.
© 2020 Elsevier Masson SAS. All rights reserved.

∗ Corresponding author at: Laboratory Block, MSK Lab, Imperial college London,White City Campus, W12 0BZ London, United Kingdom.
E-mail address: c.riviere@imperial.ac.uk (C. Rivière).

https://doi.org/10.1016/j.otsr.2019.12.020
1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Maillot C, et al. Hip resurfacing generates a more physiological gait than total hip replacement: A
case-control study. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.020
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1. Introduction
Hip replacement, either hip resurfacing (HR) or conventional
total hip replacement (THR), is a successful procedure, which
often significantly improves patients’ quality of life. Usually, the
Oxford Hip and EQ5D index scores at 3 months follow-up after hip
replacement are above 36 (maximum = 48) and 0.8 (maximum = 1),
respectively [1,2]. As a result of the good long-term lifespan of
hip implants and the development of bone-preserving component
designs, hip replacement is increasingly performed at a younger
age when patients are still active and have high expectations [3,4].
The better the anatomical reconstruction during hip replace-
ment, the more the surrounding soft-tissue balance and prosthetic
hip kinematics are likely to be close to physiological, and the
functional performance optimal [5–10]. Intra-operative technolog-
ical assistance (e.g. computer assisted surgery, robotics, custom
instruments), implant modularity (e.g. modular head/neck, mul-
tiple head diameters), bone-preserving femoral components (e.g.
hip resurfacing, neck sparing short stem), and kinematic align-
ment technique for implanting hip components [11,12] have been
developed to improve the hip anatomical restoration during THR
implantation. Compared to conventional techniques for implant-
ing THR components, HR inherently aims to preserve the unique
individual proximal femur tri-dimensional anatomy. This, in addi-
tion to being bone-preserving, may explain the excellent functional
outcomes of HR [13–15].
Functional benefits from anatomical hip restoration when per-
forming prosthetic replacement are probable but remain difficult
to demonstrate with patient reported outcome measurements
(PROMs); this may be partly explained by their high ceiling
effect [16–18]. A more sophisticated way to assess functional per-
formances between either different implant designs or various
techniques for aligning prosthetic components is to perform a gait
analysis and compare the symmetry index (SI). Treadmill gait anal-
ysis enables a quantitative and objective functional assessment
under normal (normal speed on flat ramp) and stress conditions
(high speed walking, declined and inclined ramp); this makes the
functional assessment less sensitive to the ceiling effect associated
with typical patient reported outcome measures [19]. The available
evidence suggests that the gait is relatively symmetric for healthy
subjects (SI = 4%) [20], but this degrades in osteoarthritic disease
[21], with only a partial correction after hip replacement [22].
These issues were incompletely investigated in the literature,
therefore we initiated this study to compare the gait performances
between HR and THR patients, and aimed to answer the following
questions:
• does HR result in better restoration of the frontal hip anatomical
parameters compared to THR?
• Does HR generate a more physiological gait compared to THR?
• Does the quality of the anatomical restoration after THR influence
gait performance?
Our hypothesis was that a better anatomical restoration using
HR versus THR would produce more physiological (symmetric) gait.
2. Patients and methods
2.1. Study design and population
We performed a retrospective, single-centre, single-surgeon,
pilot study. In September 2016, after screening our prospectively-
gathered database, we included 52 prosthetic adult patients (40
THRs and 12 HRs) who had had a successful unilateral hip replace-
ment (satisfied patients with Oxford Hip Score = 44) between 2011
Please cite this article in press as: Maillot C, et al. Hip resurfacing generates a more physiological gait than total hip replacement: A
case-control study. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.020
Table 1
Demographic and clinical data for the THR and HR groups.
THR HR p-value
Age 64 (61; 69) 58 (55; 63) 0.022a
Sex (M/F) 14/26 9/3 0.015a
BMI 24.57 (22; 27) 25.90 (25; 27.5) 0.213
Oxford Hip Score 46 (45; 48) 46 (44; 47) 0.503
All variables are expressed as median (lower quartile, upper quartile). THR: total hip
replacement; HR: hip resurfacing.
a
Statistically significant difference.
and 2014 for severely debilitating primary hip osteoarthritis, had
a native healthy contralateral hip, had no comorbidity liable to
affect their functional performance (e.g. lower limb osteoarticu-
lar disorders or joint replacement, severe obesity, sagittal spinal
imbalance, cardiac or neuromuscular disorder), had undertaken a
gait analysis at a minimum of 7 months post-surgery, and had com-
plete demographics, functional, radiographic, and gait data. All data
were prospectively collected, at the exception of the radiographic
measurements. Median age and BMI for the whole cohort was 63
years (from 57 to 67), and 25.4 kg.m−1 (from 22.73 to 27.2), respec-
tively. The demographic and functional data for HR and THR groups
are displayed in Table 1: there were significant difference in terms
of sex and age between groups. A sample size was not calculated,
as the effect size of HR and THR on the gait symmetry index was
unknown at the time we designed the study. All participants gave
their written consent, and ethical approval (10/HO807/101) was
gained before the study started.
2.2. Surgical procedure
Forty patients were conventionally implanted with a THR
implant (FurlongTM Hip System using either conventional [6A]
or short EVO [34A] FurlongTM stems; JRI, Sheffield, England) and
twelve patients with a Birmingham Hip ResurfacingTM (Smith and
Nephew, Memphis, TN). Surgeries were all performed with man-
ual instrumentation, through a posterior approach, and with repair
of the capsule and external rotators at the end of the procedure.
THR patients were implanted with either 32 or 36 mm heads, and
their components were systematically aligned as follow: acetabular
cup inclined 40◦ and anteverted 15◦ relative to the anterior pelvic
plane, femoral stem anteverted 10◦ to 15◦ relative to the posterior
condylar line.
2.3. Gait assessment
Subjects performed a gait analysis under both normal and stress
conditions at a median of 14 months (7 to 16 months) post-surgery
on an instrumented treadmill (Kistler Gaitway; Kistler Instrument
Corporation, Amherst, NY), using a standardized published method
[23]. After a period of familiarisation, the patients had their gait
recorded for different walking speed conditions (3.5 km/h followed
by sequential incrementation of 0.5 km/h until the patient self-
determined their top walking speed) and ramp inclinations (flat
surface, 5◦ and 10◦ incline, then 5◦ decline). Six kinetic ground reac-
tion force parameters were measured for both the prosthetic and
the contralateral native hips of each patient: weight acceptance
(heel strike) peak force and peak time, mid support force and time,
push off (toe off) peak force and peak time. The data analysis was
performed using custom software written using Matlab R2015b.
2.4. Radiographic study
Each patient had a standing antero-posterior pelvis X-ray done
at 6 weeks post-surgery. Images were imported as DICOM files
into OsiriX MD 7.0 image processing software in order to make
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Fig. 1. Radiographical parameters assessed for the operated and non-operated hip
on supine antero-posterior pelvis postoperative radiographs. 1: vertical centre of
rotation (VCOR) as perpendicular distance from the COR of the hip to the inter-
teardrop line; 2: acetabular offset = horizontal COR (HCOR) as distance between the
vertical COR line and the teardrop; 3: femoral offset (FO) as perpendicular distance
from the centre of rotation to the femoral shaft line, and; 4: limb-length (LL) as
perpendicular distance from the teardrop to the apex of the lesser trochanters. Two
combined parameters were calculated: global horizontal offset (GHO = 2 + 3) was
defined as the sum of femoral offset (FO) + acetabular offset (HCOR); and global
vertical offset (GVO = 4-1) as the difference in Limb-length (LL) – vertical centre of
rotation (VCOR).
the following measurements (Fig. 1): vertical (VCOR) and hori-
zontal (HCOR) centre of rotation offsets, femoral offset (FO), and
limb-length (LL). In addition to the measured parameters, two
combined parameters were calculated: the global horizontal offset
(GHO = FO + HCOR) and the global vertical offset (GVO = LL − VCOR).
2.5. Statistical analysis
We pooled together the gait acquisition results for normal and
fast speed according to published cut off values (around 6 km/h and
5.5 km/h for men and women, respectively, with some variations
based on the age) [24]. Gait data were normalized for weight and
height in order to enable cross-group comparison.
We calculated the gait symmetry index (SI) between the
prosthetic and the contralateral native limb for weight accep-
tance peak force, mid support force and push off peak
force by using the equation (1) “SIX = (XProsthetic − XNativ CL )/
[0.5(XProsthetic + XNativ CL )] × 100” [15], where XProsthetic is a gait
variable recorded for the prosthetic side and XNative CL is the cor-
responding variable for the contralateral native hip. Values closer
to zero indicated a perfectly symmetrical gait.
To account for the absence of X-ray calibration, we com-
puted the “prosthetic/native contralateral” ratio for each radio-
graphical biomechanical parameter by using the equation (2)
“RatioY = [(Yprosthetic − YNative CL )/YNative CL ] × 100”, where YProsthetic
and YNative CL represent the radiographic variable recorded for the
prosthetic and the native contralateral limb, respectively. The
RatioY values represent the percentage difference between the
prosthetic and the reference native contralateral measures, with
the zero-value indicating a perfect symmetry between them. A pos-
itive value indicates a prosthetic measure is superior than the native
contralateral one.
In order to further assess the influence of altering the hip
anatomy on the gait performances, we classified the peri-prosthetic
soft-tissue balance into 6 different groups, as illustrated in Fig. 2,
by combining the RatioGHO and RatioGVO . We selected a thresh-
old of 15% of variation between prosthetic and native contralateral
Please cite this article in press as: Maillot C, et al. Hip resurfacing generates a more physiological gait than total hip replacement: A
case-control study. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.020
3
Table 2
Ratio prosthetic hip/healthy contralateral hip of independent radiographical param-
eters for the THR and HR groups.
Total hip replacement Hip resurfacing
(n = 40) (n = 12)
Ratio vertical centre of 7.58 (−9.1; 27.7) 12.92 (−6.8; 25.3)
rotation (VCOR) – (%)
Ratio horizontal COR 0 (−4; 2,6) −2.02 (−6.3; 2.6)
(HCOR) – (%)
a
Ratio femoral offset 4.56a (−1.5; 13.4) −8.01a (−13.4; 3.3)
(FO) – (%)
Ratio limb-length (LL) 0 (−3.1; 3.3) −2.8 (−13.9; 3.8)
– (%)
a
Ratio global horizontal 3.03a (−0.7; 8.1) −3.96a (−10.4; 0)
offset (GHO) – (%)
Ratio global vertical −4.99 (−17.4; 8.9) −13.47 (−41.5; 15.5)
offset (GVO) – (%)
All variables are expressed as median (lower quartile, upper quartile). The ratio
values obtained are the percentage of variation of prosthetic radiological variables
using the healthy contralateral side as a reference. Values closer to zero indicated a
perfectly symmetrical radiological parameter. THR: total hip replacement; HR: hip
resurfacing.
a
Significant difference between THR and HR.
parameters (GHO or GVO) as this has been reported to be the min-
imum value having a biomechanical and clinical influence [25,26].
All the variables were presented as median (lower quartile,
upper quartile). The radiographical and gait parameters for THR
and HR groups under every gait condition were compared by
using the Mann Whitney U test, and the data from each gait
condition compared by using the Kruskal-Wallis test. Statistical sig-
nificance (p-value) for these tests was set at 0.05. Each measured
radiographic parameter (RatioY and each group of peri-prosthetic
soft-tissue tension) was correlated with the gait (SIX ) parameters
for each gait condition (flat surface – normal speed [FN], flat surface
– fast speed [FF], incline – normal speed [I], and decline – normal
speed [D]), by using the Pearson correlation test. Statistical signif-
icance (p-value) of the Pearson coefficients was adjusted at 0.03
to correct for multiple analyses. Statistical analysis was performed
using IBM SPSS, version 21.
3. Results
The RatioY for each radiographical parameter and the distribu-
tion of patients amongst groups of “prosthetic soft-tissue tension”
are illustrated in Tables 2 and 3, respectively. Compared to the
native contralateral side, the HR procedure tended to decrease all
independent anatomical radiographic parameters with the excep-
tion of the VCOR, whilst the THR procedure tended to increase
them; the difference between HR and THR was only statistically
significant for FO and GHO (Table 2). Whilst both procedures repro-
ducibly restored the native HCOR, there was more variability in the
restoration of the FO (Table 2). Regarding the combined parame-
ters (Table 3), 0% (0/12) and 25% (3/12) of HR procedures, and 10%
(4/40) and 18% (7/40) of THR procedures, significantly (>15% com-
pared to the healthy contralateral hip) increased the GHO and GVO,
respectively. Only 50% of THR and 25% of HR procedures closely
anatomically (±15%) recreated both GHO and GVO.
The SIx and average gait kinetic parameters for HR and THR
patients are illustrated in Table 4 and Fig. 3, respectively. Both HR
and THR patients had a relatively symmetric gait under normal
conditions (normal walking speed and flat ramp), with a symme-
try index of 0.62% and 3.14% respectively. Knowing that healthy
people may have a symmetry index of up to 4%, 17/40 (42.5%) of
THR patients and 5/12 (42%) of HR patients were under this thresh-
old. Regarding stress conditions, increasing the walking speed was
more deleterious on the symmetry of the gait than inclining the
ramp for both the HR and THR groups. At high walking speed, the
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Fig. 2. Soft-tissue balancing. GHO: global horizontal offset; GVO: global vertical offset.

Table 3
Distribution of patients according to composite radiological hip parameters.

Ratio global horizontal offset

<−15% Restored >+15%

Ratio global vertical offset

<−15% None 15 patients: HR 6/12 (50%)/THR 9/40 (22.5%) 3 patients: THR 3/40 (7.5%)
Restored None 23 patients: HR 3/12 (25%)/THR 20/40 (50%) 1 patient: THR 1/40 (2.5%)
>15% None 10 patients: HR 3/12 (25%)/THR 7/40 (17.5%) None

THR: total hip replacement, HR: hip resurfacing.

Table 4
Gait symmetry index (SI) between prosthetic and healthy contralateral side under different gait conditions for the THR and HR groups.

Groups Speed Plan SI Weight SI Weight SI Mid support SI Mid support SI Push off peak SI Push off peak
acceptance acceptance force time force time
peak force peak time

THR Normal Flat −3.14 (−5.7; 1.0) 4.8 (−0.6; 10.4) 1.7 (−1.1; 4.7) −0.02 (−3.7; 3.9) −1.05 (−3.7; 1.1) −0.73 (−2.6; 1.3)
Fast −5.74a (−7.1; −1.3) 4.03a (−3.4; 7.3) 2.51a (−1.1; 6.4) −0.13 (−3.3; 1.7) −2.04 (−3.1; −0.7) −1.16 (−3.7; 0.1)
Normal 10◦ incline −1.79a (−3.5; 1.7) 3.03 (−2.4; 10.2) 2.03a (−0.1; 3.8) −1.35a (−4.2; 3.1) −1.5a (−4.2; 1.8) 0.01 (−4.3; 2.0)
5◦ incline −0.54a (−3.4; 1.4) 3.33a (−2.0; 12.0) 1.02a (−0.9; 2.0) −0.73a (−4.1; 5.9) −1.9a (−5.5; 1.4) 0 (−4.2; 1.8)
Decline −1.28a (−4.1; 0.5) −4.59a (−8.6; 8.5) −0.34a (−1.5; 1.6) −0.31a (−3.5; 3.8) −1.92a (−3.7; 1.7) −1.24 (−7.2; 0.9)
HR Normal Flat −0.62 (−2.9; 1.7) 1.04 (−3.5; 7.0) 0.07 (−2.2; 3.0) −1.59 (−3.6; 0.8) −0.79 (−2.0; 1.6) −1.31 (−2.2; 2.5)
Fast −2.09a (−5.1; 0.8) −3.01a (−7.0; 0.2) −2.62a (−12; 9.1) −0.66 (−3.8; 4.0) −0.46 (−2.0; 2.0) −0.63 (−3.2; 3.8)
Normal 10◦ incline −1.53a (−3.6; 1.0) −1.69 (−3.8; 0.4) 1.15a (−2.4; 3.8) −6.52a (−10; 0.5) −0.37 (−4.2; 3.1) −2.02 (−3.1; −0.1)
5◦ incline −0.32a (−1.3; 0.4) 0.42 (−3.4; 6.9) 1.48a (−2.7; 3.3) −1.47a (−4.0; 2.6) −1.21 (−3.6; 2.0) −0.42 (−4.9; 1.7)
Decline 2.04a (−1.4; 2.8) 4.52a (−8.2; 9.8) −0.39 (−3.3; 2.2) −1.49a (−2.7; 3.8) 2.07a (0.5; 3.4) −0.16 (−0.9; 2.9)

All variables are expressed as median (lower quartile, upper quartile), no unit. The SI values obtained are the percentage of variation of prosthetic gait variables using the
healthy contra-lateral side as a reference; values closer to zero indicate a perfectly symmetrical gait. THR: total hip replacement; HR: Hip resurfacing.
a
Statistically significant difference between normal speed on flat plane and other condition within THR and HR groups.

symmetry index degraded for both groups, but the gait remained
more symmetric in the HR group, as illustrated by the SIx for weight
acceptance at fast flat exercise being 2.09% and 5.74% for HR and
THR patients (p = 0.159), respectively.
The gait symmetry indices between soft-tissue tension groups
under different gait conditions are illustrated in Table 5. We
were unable to detect significant gait differences between THR
patients having various estimated “peri-prosthetic soft-tissue bal-
ance” (Table 5). In addition, we were unable to detect any significant
relationship between gait performances (SIX ) and radiographically
measured hip frontal anatomical parameters (Table 6).
4. Discussion
Our main findings are that HR procedure is more consistent than
conventional THR in generating a more physiological gait under
stress conditions, and radiographical estimation of the quality of
the frontal anatomical hip restoration is of poor value to predict
gait performances of THR patients. We found the HR procedure
mainly reduced the medial FO, while the THR procedure increased
it, and the change in GHO after HR and THR procedures was mainly
the consequence of change in FO. Our results are in line with those
of Silva et al. [27], who compared 50 HR and 40 conventional THR
patients; the authors found that HR and THR patients had prosthetic
FOs that were respectively 8 mm reduced and 5 mm increased
compared to the healthy contralateral hip. Difference in surgical
techniques between HR and THR procedures may partly explain
these findings. When performing HR, the medio-lateral position-
ing of the femoral component is determined by the location of the
superior femoral neck cortico-cancellous junction; the frequently
observed pistol grip deformity on the osteoarthritic hips of young
patients eligible for HR may favour an excessively medial location

Please cite this article in press as: Maillot C, et al. Hip resurfacing generates a more physiological gait than total hip replacement: A
case-control study. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.020
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Fig. 3. This graph illustrates the average ground reaction force’s symmetric indexes (numerical scale) that were measured on total hip replacement (THR) and hip resurfacing
(HR) patients during the stance phase at the weight acceptance, mid support, and push off. The closer the symmetric index is to zero, the more symmetric the prosthetic and
healthy contralateral hips.

Table 5
Gait symmetry index between soft-tissue tension groups under different gait conditions for the whole group.

Speed Plan Gait symmetric index Group B Group C Group D Group E p-value

Normal Flat Weight acceptance peak force −2.22 (−3.8; 0.4) −3.56 (−6.7; 0.3) 0.37 (−1.5; 2.1) −2.03 (−5.3; 1.8) 0.462
Mid support force 2.65 (−0.9; 3.5) 1.76 (−1.5; 4.8) −1.02 (−3.4; 0.3) 1.46 (−1.0; 2.9) 0.609
Push off peak force −0.9 (−3.5; 0.8) −1.34 (−3.6; 0.8) 1.12 (1.1; 2.4) −1.52 (−4.1; 1.4) 0.421
Fast Weight acceptance peak force −1.29 (−6.6;−0.5) −6.45 (−8.2;−2) −0.51 (−3.4; 2.3) −5.27 (−5.5;−4.7) 0.588
Mid support force 1.9 (−2.4; 6.4) 4.27 (−4.3; 7.9) −8.53 (−12.3;−4.7) 3.03 (−1.4; 10.4) 0.514
Push off peak force −2.17 (−5.3;−0) −1.7 (−3.2;−0.3) 3.7 (1.7; 5.7) −0.98 (−2;−0.4) 0.290
Normal 10◦ incline Weight acceptance peak force −1.78 (−3.2; 1.6) −3.15 (−5.8; 0.2) 1.99 (1.9; 2) −1.23 (−2.5; 1.4) 0.388
Mid support force 1.38 (−0.9; 5.6) 0.94 (−1.1; 3.6) 2.87 (2.8; 2.8) 2.07 (1.2; 3.6) 0.880
Push off peak force 0.09 (−3.5; 3.1) −1.46 (−4.6; 2) −1.53 (−1.5;−1.6) −0.83 (−3.7; 0.5) 0.914
5◦ incline Weight acceptance peak force −0.41 (−3.4; 1.5) −0.68 (−4.3; 0.8) 1.85 (1.8; 1.9) −0.17 (−2.6; 3.5) 0.317
Mid support force 1.69 (−1.5; 2.6) 1.35 (−0.7; 2.3) −0.41 (−0.4;−0.5) 0.43 (−1; 2) 0.878
Push off peak force −1.61 (−5.5; 2.2) −1.19 (−4.1; 1.2) −1.36 (−1.3;−1.4) −2.33 (−4; 0.1) 0.991
Decline Weight acceptance peak force −0.96 (−1.7; 2.7) 2.04 (−1.3; 2.3) −1.56 (−1.5;−1.6) −2.02 (−4.4;−0.2) 0.740
Mid support force 0.75 (−2.2; 2.1) −0.34 (−0.5; 2.3) 1.14 (1.1; 1.2) −1.53 (−3.8;−0.4) 0.736
Push off peak force 0.81 (−1.4; 1.7) −1.92 (−3.6; 2.5) 5.03 (5; 5.1) 1.59 (0.1; 2.2) 0.443

To assess the influence of altering the hip anatomy on the gait performances, we classified the peri-prosthetic soft-tissue balance into 6 different groups (Fig. 2), by combining
the RatioGHO and RatioGVO . Group B: moderate soft-tissue loosening. GVO or GHO ratios restored while the other ratio had changes less than 15%; Group C: normal soft-
tissue tension. GHO and GVO ratios restored; Group D: slight soft-tissue tension change. GHO ratio had increased >15% and GVO ratio decreased <−15% or GVO ratio had
increased >15% and GHO ratio decreased <−15%; Group E: moderate soft-tissue stretching. GHO ratio restored while GVO increased >15% or GVO ratio restored while GHO
increased >15%; Groups A and F are not illustrated because they did not include any subject. All the variables were presented as medians (lower quartile, upper quartile).

of the superior femoral neck cortico-cancellous junction. In con-
trast, the FO generated with THR is mainly dictated by the residual
joint laxity during the piston test, with the capacity for surgeons
to reduce this laxity by artificially increasing the FO via selection
of high offset stem design and/or high neck length (L, XL) modu-
lar head options. As surgeons generally fear prosthetic instability
with THR, they tend to reduce the residual laxity by voluntarily
tensioning the peri-prosthetic soft-tissue.
Overall, we found that HR generated a more physiological gait
than THR, mainly under speed conditions. Nevertheless, none of
the differences in gait performance between the two procedures
reached statistical significance. Few studies report on compari-
son of gait performances between HR and THR patients. Peterson
et al. [28] and Lavigne et al. [29] did not find significant gait
performance differences between HR patients and individuals hav-
ing been implanted with 28 mm head THA [28] and large diameter
head THR [29]. While the former authors [28] compared gait per-
formances under normal conditions (˜4.4 km/h walking speed),
the latter [29] investigated normal and stress (fast 6.5 km/h walk-
ing speed) conditions. In contrast, others studies found that HR
restored a more physiological gait pattern under higher speed
conditions, when compared to THR [30,31]. Gerhardt et al. [30]
found HR patients reached a higher walking speed, and preserved
a more physiological weight acceptance and range of hip flexion
compared to THR patients. Aquil et al. [31] also showed that increas-
ing walking speed correlated strongly with differences in weight
acceptance (r = 0.9) and push off force (r = 0.79) between the two
limbs. The more symmetrical gait achieved with HR highlights the

Please cite this article in press as: Maillot C, et al. Hip resurfacing generates a more physiological gait than total hip replacement: A
case-control study. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.020
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Table 6
This table illustrates the relationship between radiographic frontal hip parameters and gait performances when walking at normal speed on a flat plane.

SI weight SI weight SI Mid SI Mid SI Push off SI Push off

acceptance peak acceptance peak support force support time peak force peak time
force time

THR
Ratio vertical centre of rotation (VCOR) r = 0.129 r = 0.100 r = −0.144 r = 0.075 r = 0.075 r = −0.36
p = 0.429 p = 0.538 p = 0.376 p = 0.646 p = 0.644 p = 0.824
Ratio horizontal COR (HCOR) r = 0.158 r = −0.108 r = −0.137 r = −0.052 r = 0.089 r = 0.098
p = 0.332 p = 0.505 p = 0.399 p = 0.748 p = 0.586 p = 0.547
Ratio femoral offset (FO) r = 0.194 r = 0.104 r = −0.145 r = 0.030 r = 0.122 r = −0.055
p = 0.231 p = 0.524 p = 0.371 p = 0.854 p = 0.491 p = 0.736
Ratio limb-length (LL) r = −0.003 r = 0.005 r = 0.034 r = 0.107 r = −0.135 r = 0.106
p = 0.984 p = 0.974 p = 0.835 p = 0.513 p = 0.406 p = 0.515
Ratio global horizontal offset (GHO) r = 0.336 r = 0.030 r = −0.275 r = −0.011 r = 0.199 r = 0.004
HR p = 0.034 p = 0.853 p = 0.086 p = 0.949 p = 0.217 p = 0.980
Ratio global vertical offset (GVO) r = 0.033 r = −0.093 r = 0.005 r = −0.014 r = −0.057 r = 0.128
p = 0.839 p = 0.570 p = 0.977 p = 0.933 p = 0.725 p = 0.430
Ratio vertical centre of rotation (VCOR) r = 0.245 r = −0.039 r = −0.062 r = 0.361 r = 0.171 r = 0.470
p = 0.442 p = 0.904 p = 0.847 p = 0.249 p = 0.595 p = 0.123
Ratio horizontal COR (HCOR) r = −0.179 r = 0.096 r = 0.431 r = 0.193 r = −0.333 r = −0.188
p = 0.579 p = 0.766 p = 0.162 p = 0.548 p = 0.289 p = 0.558
Ratio femoral offset (FO) r = 0.541 r = −0.644 r = −0.476 r = −0.461 r = 0.028 r = −0.373
p = 0.069 p = 0.024a p = 0.117 p = 0.131 p = 0.932 p = 0.233
Ratio limb-length (LL) r = −0.432 r = 0.213 r = 0.307 r = 0.047 r = −0.115 r = −0.16
p = 0.161 p = 0.507 p = 0.332 p = 0.884 p = 0.722 p = 0.962
Ratio global horizontal offset (GHO) r = 0.401 r = −0.529 r = −0.231 r = −0.271 r = −0.107 r = −0.351
p = 0.196 p = 0.077 p = 0.70 p = 0.395 p = 0.742 p = 0.263
Ratio global vertical offset (GVO) r = −0.422 r = 0.237 r = 0.402 r = 0.362 r = −0076 r = 0.399
p = 0.172 p = 0.458 p = 0.195 p = 0.247 p = 0.813 p = 0.199

SI: Gait Symmetry Index; THR: total hip replacement; HR: hip resurfacing.
a
Statistical significance (p = 0.03).

importance of preserving the femoral neck (bone proprioceptors
and physiological soft-tissue tension) and native head size, which
seems to prevent generation of aberrant prosthetic hip biomechan-
ics [13,32,33].
We were unable to detect significant gait performance differ-
ences between THR patients with various estimated quality of
anatomical reconstruction and soft-tissue tension (Table 5). The
radiographic estimation of the quality of the frontal anatomical
hip restoration therefore seems to be of poor value in predict-
ing the gait performance of THR patients. The study limitations
mentioned below probably explain our findings. It is probable that
restoring both axial (neck anteversion/anterior offset) and frontal
(length and FO) native anatomical femoral neck parameters when
performing THR is of importance in order to generate physio-
logical peri-articular soft-tissue tension, hip kinematics, and gait
performance. The fact that the conventional technique for THR (sys-
tematic non physiological implantation) does not primarily aim to
restore the constitutional hip axial anatomy may explain why solely
restoring the frontal hip anatomy when conventionally implanting
THR components is not sufficient to generate significant gait bene-
fit. This also probably explains the functional superiority of HR over
THR, and further supports the relevance of performing anatomic or
kinematic implantation of THR components (kinematic alignment
technique for THR) [11,12]. In contrast with our study, a few papers
found a relationship:
• reduction of physiological femoral offset compromising abductor
function has been reported: Sariali et al. [25] found that a decrease
in FO affected gait symmetry (reduced ROM and lower maximal
swing speed) between operated and healthy limbs; Asayama et al.
[26] found a decrease of 15% in FO generates weakness of the
abductor muscle, while a larger femoral offset decreases the hip
abductor muscle force required to walk;
• the functional effect of post-THR limb-length discrepancy (LLD)
remains less clear: Rösler et al. [34] found no significant
disturbance of gait kinematics in the case of asymptomatic
infra-centimetric LLD in 26 patients; Li et al. [35] compared
patients with symptomatic (15 patients, average LLD 20 mm –
11.9 to 28.1 mm) or asymptomatic LLD (15 patients, average LLD
10.3 mm – 4.7 to 15.9 mm) and found that symptomatic patients
had decreased gait velocity by 0.2 m/s, decreased stride length by
0.3 m, and a 34% higher mid-stance ground reaction force;
• the effect on gait performance of the restoration of COR has
scarcely been studied: Rösler et al. [34] found that only a proximal
location of the prosthetic COR affected gait parameters; Tsai et al.
[36] found that COR medialisation and leg lengthening increased
the internal rotation of the implanted hip when walking;
• finally, the head diameter seems to have a negligible impact on
gait performances [37].
It is important to acknowledge a few limitations of our methods
that may affect the generalization of our results. Firstly, our findings
are likely to be affected by cofounding bias due to the absence of
randomisation, matching, and adjustment processes. However, this
study could be considered as a basis for future randomized studies
by providing basic data to calculate power and sample. Secondly,
our study had an insufficient number of HR patients, resulting in
statistical tests often being underpowered with the potential sub-
sequent generation of statistical errors type 2. To overcome this
limitation, we only used non parametrical tests. Thirdly, radio-
graphic measurements of the FO are known to be inaccurate when
compared to 3D measurements, and poorly estimate the true FO
[38,39]. This limitation renders difficult the estimation of both the
hip anatomical restoration and the peri-articular soft-tissue ten-
sion from radiographic pelvis X-rays, and therefore attenuates the
relevance of our results for question 3. Despite this limitation, the
data provided in the current study were clinically relevant consid-
ering that the large majority (72%) of FO measurements on plain
X-rays had an error less than 5 mm versus CT-scan [40]. Fourthly,
we only estimated the prosthetic anatomical reconstruction in the
frontal plane on pelvic radiograph, neglecting the axial plane. How-
ever, alteration of the native individual femoral neck anteversion

Please cite this article in press as: Maillot C, et al. Hip resurfacing generates a more physiological gait than total hip replacement: A
case-control study. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.020
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(axial plane) when performing conventional THR would probably
negatively influence peri-prosthetic soft-tissue balance, hip kine-
matics, and ultimately the gait performance. Further investigations
are needed to assess the influence of axial hip anatomy restoration
on THR function. Finally, we took the contra-lateral healthy hip
anatomy as a reference to determine the quality of the prosthetic
anatomical reconstruction, despite the fact that hips are often not
completely symmetric. However, severe hip asymmetry is unlikely
in our study population as our patients undertook hip replacement
to cure a primary osteoarthritis, and they were known to have no
other comorbidities affecting their gait performance [41].
5. Conclusions
The HR procedure is more consistent than conventional THR
in generating a more physiological gait under stress conditions.
Radiographic estimation of the quality of the frontal anatomical
hip restoration is of poor value to predict gait performances of THR
patients.
Disclosure of interest
Outside the current study Charles Rivière declares being a paid-
consultant for Medacta, and Justin Cobb declares being a consultant
for Biomet-Zimmer, Mathortho, to receive fees from Microport, ,
and to be involved in the development of a ceramic hip resurfacing.
The other authors declare that they have no competing interest.
Funding
The institution received funding from Depuy for this project.
Contribution
Cedric Maillot: the conception and design of the study, or acqui-
sition of data, or analysis and interpretation of data, drafting the
article or revising it critically for important intellectual content,
final approval of the version to be submitted and statistics.
Edouard Auvinet: the conception and design of the study, or
acquisition of data, or analysis and interpretation of data, drafting
the article or revising it critically for important intellectual content,
final approval of the version to be submitted and statistics.
Ciara Harman: drafting the article or revising it critically for
important intellectual content and final approval of the version to
be submitted.
Charles Rivière: the conception and design of the study, or acqui-
sition of data, or analysis and interpretation of data, drafting the
article or revising it critically for important intellectual content
and final approval of the version to be submitted. Justin Cobb per-
formed the prosthetic implantations, was involved in conception
and design of the study, and revising the manuscript critically for
important intellectual content and final approval of the version to
be submitted.
References
[1] Naal FD, Impellizzeri FM, Lenze U, Wellauer V, von Eisenhart-Rothe R, Leu-
nig M. Clinical improvement and satisfaction after total joint replacement: a
prospective 12-month evaluation on the patients’ perspective. Qual Life Res
2015;24:2917–25.
[2] Peters RM, van Beers LW, van Steenbergen LN, Wolkenfelt J, Ettema HB, et al.
Similar superior patient-reported outcome measures for anterior and postero-
lateral approaches after total hip arthroplasty: postoperative patient-reported
outcome measure improvement after 3 months in 12,774 primary total hip
arthroplasties using the anterior, anterolateral, straight lateral, or posterolat-
eral approach. J Arthroplasty 2018;33:1786–93.
Please cite this article in press as: Maillot C, et al. Hip resurfacing generates a more physiological gait than total hip replacement: A
case-control study. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.020
7
[3] Girard J, Lons A, Ramdane N, Putman S. Hip resurfacing before 50 years of age:
a prospective study of 979 hips with a mean follow-up of 5.1 years. Orthop
Traumatol Surg Res 2018;104:295–9.
[4] Girard J, Lons A, Pommepuy T, Isida R, Benad K, Putman S. High-impact
sport after hip resurfacing: the ironman triathlon. Orthop Traumatol Surg Res
2017;103:675–8.
[5] Sariali E, Klouche S, Mamoudy P. Investigation into three dimensional hip
anatomy in anterior dislocation after THA. Influence of the position of the hip
rotation centre. Clin Biomech 2012;27:562–7.
[6] Baghdadi YMK, Larson AN, Sierra RJ. Restoration of the hip center during THA
performed for protrusio acetabuli is associated with better implant survival.
Clin Orthop Relat Res 2013;471:3251–9.
[7] Sakalkale DP, Sharkey PF, Eng K, Hozack WJ, Rothman RH. Effect of femoral
component offset on polyethylene wear in total hip arthroplasty. Clin Orthop
Relat Res 2001;388:125–34.
[8] Kleemann RU, Heller MO, Stoeckle U, Taylor WR, Duda GN. THA loading aris-
ing from increased femoral anteversion and offset may lead to critical cement
stresses. J Orthop Res 2003;21:767–74.
[9] Hayashi S, Nishiyama T, Fujishiro T, Hashimoto S, Kanzaki N, Nishida K, et al.
Excessive femoral offset does not affect the range of motion after total hip
arthroplasty. Int Orthop 2013;37:1233–7.
[10] Windhagen H, Chincisan A, Choi HF, Thorey F. Soft-tissue balance in short and
straight stem total hip arthroplasty. Orthopedics 2015;38:14–20.
[11] Rivière C, Harman C, Parsons T, Villet L, Cobb J, Maillot C. Kinematic alignment
versus conventional techniques for total hip arthroplasty: a retrospective case
control study. Orthop Traumatol Surg Res 2019;105:895–905.
[12] Rivière C, Maillot C, Harman C, Cobb J. Kinematic alignment technique for total
hip arthroplasty. Sem Art 2018;29:330–43.
[13] Girard J, Lavigne M, Vendittoli PA, Roy AG. Biomechanical reconstruction of
the hip: a randomised study comparing total hip resurfacing and total hip
arthroplasty. J Bone Joint Surg Br 2006;88:721–6.
[14] Herman KA, Highcock AJ, Moorehead JD, Scott SJ. A comparison of leg length
and femoral offset discrepancies in hip resurfacing, large head metal-on-metal
and conventional total hip replacement: a case series. J Orthop Surg 2011;6:65.
[15] Arnould A, Boureau F, Benad K, Pasquier G, Migaud H, Girard J. Computed
tomography evaluation of hip geometry restoration after total hip resurfacing.
Orthop Traumatol Surg Res 2015;101:571–5.
[16] Huo SC, Wang F, Dong -J, Wei W, Zeng JQ, Huang HX, et al. Short-stem prostheses
in primary total hip arthroplasty: a meta-analysis of randomized controlled
trials. Medicine (Baltimore) 2016;95:e5215.
[17] Liang HD, Yang WY, Pan JK, Huang HT, Luo MH, Zeng LF, et al. Are short-
stem prostheses superior to conventional stem prostheses in primary total hip
arthroplasty? A systematic review and meta-analysis of randomised controlled
trials. BMJ Open 2018;8:e021649.
[18] Ortiz-Declet VR, Iacobelli DA, Yuen LC, Perets I, Chen AW, Domb BG. Birming-
ham hip resurfacing vs total hip arthroplasty: a matched-pair comparison of
clinical outcomes. J Arthroplasty 2017;32:3647–51.
[19] Hamilton DF, Loth FL, Giesinger JM, Giesinger K, MacDonald DJ, Patton JT, et al.
Validation of the English language Forgotten Joint Score-12 as an outcome mea-
sure for total hip and knee arthroplasty in a British population. Bone Joint J
2017;99:218–24.
[20] Herzog W, Nigg BM, Read LJ, Olsson E. Asymmetries in ground reaction force
patterns in normal human gait. Med Sci Sports Exerc 1989;21:110–4.
[21] Tanaka R, Shigematsu M, Motooka T, Mawatari M, Hotokebuchi T. Factors
influencing the improvement of gait ability after total hip arthroplasty. J Arthro-
plasty 2010;25:982–5.
[22] Ewen AM, Stewart S, St Clair Gibson A, Kashyap SN, Caplan N. Post-operative
gait analysis in total hip replacement patients – A review of current literature
and meta-analysis. Gait Posture 2012;36:1–6.
[23] Aqil A, Wiik A, Zanotto M, Manning V, Masjedi M, Cobb JP. The effect of hip
arthroplasty on osteoarthritic gait: a blinded, prospective and controlled gait
study at fast walking Speeds. J Arthroplasty 2016;31:2337–41.
[24] Oberg T, Karsznia A, Oberg K. Basic gait parameters: reference data for normal
subjects, 10–79 years of age. J Rehabil Res Dev 1993;30:210.
[25] Sariali E, Klouche S, Mouttet A, Pascal-Moussellard H. The effect of
femoral offset modification on gait after total hip arthroplasty. Acta Orthop
2014;85:123–7.
[26] Asayama I, Chamnongkich S, Simpson KJ, Kinsey TL, Mahoney OM. Recon-
structed hip joint position and abductor muscle strength after total hip
arthroplasty. J Arthroplasty 2005;20:414–20.
[27] 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;86:40–6.
[28] Petersen MK, Andersen NT, Mogensen P, Voight M, Søballe K. Gait analysis
after total hip replacement with hip resurfacing implant or mallory-head exeter
prosthesis: a randomised controlled trial. Int Orth 2011;35:667–74.
[29] Lavigne M, Therrien M, Nantel J, Roy A, Prince F, Vendittoli PA. The functional
outcome of hip resurfacing and large-head THA is the same: a randomized,
double-blind study. Clin Orthop Relat Res 2010;468:326–36.
[30] Gerhardt DM, Mors TG, Hannink G, Van Susante JL. Resurfacing hip arthroplasty
better preserves a normal gait pattern at increasing walking speeds compared
to total hip arthroplasty. Acta Orthop 2019;28:1–9.
[31] Aqil A, Drabu R, Bergmann JH, Masjedi M, Manning V, Andrews B, et al. The
gait of patients with one resurfacing and one replacement hip: a single blinded
controlled study. Int Orthop 2013;37:795–801.
G Model
OTSR-2554; No. of Pages 8 ARTICLE IN PRESS
8 C. Maillot et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2020) xxx–xxx

[32] Nantel J, Termoz N, Vendittoli PA, Lavigne M, Prince F. Gait patterns after total
hip arthroplasty and surface replacement arthroplasty. Arch Phys Med Rehabil
2009;90:463–9.
[33] Szymanski C, Thouvarecq R, Dujardin F, Migaud H, Maynou C, Girard J.
Functional performance after hip resurfacing or total hip replacement: a com-
parative assessment with non-operated subjects. Orthop Traumatol Surg Res
2012;98:1–7.
[34] Rösler J, Perka C. The effect of anatomical positional relationships on kinetic
parameters after total hip replacement. Int Orthop 2000;24:23–7.
[35] Li J, McWilliams AB, Jin Z, Fisher J, Stone MH, Redmond AC, et al. Unilateral
total hip replacement patients with symptomatic leg length inequality have
abnormal hip biomechanics during walking. Clin Biomech 2015;30:513–9.
[36] Tsai TY, Li JS, Dimitriou D, Kwon YM. Does component alignment affect
gait symmetry in unilateral total hip arthroplasty patients? Clin Biomech
2015;30:802–7.
[37] Zagra L, Anasetti F, Bianchi L, Licari V, Giacometti Ceroni R. No Difference in gait
recovery after THA with different head diameters: a prospective randomized
study. Clin Orthop Relat Res 2013;471:3830–7.
[38] Lazennec JY, Chometon Q, Folinais D, Robbins CB, Pour AE. Are advanced three-
dimensional imaging studies always needed to measure the coronal knee
alignment of the lower extremity? Int Orthop 2017;41:917–24.
[39] Lazennec JY, Brusson A, Dominique F, Rousseau MA, Pour AE. Offset and antev-
ersion reconstruction after cemented and uncemented total hip arthroplasty:
an evaluation with the low-dose EOS system comparing two- and three-
dimensional imaging. Int Orthop 2015;39:1259–67.
[40] Lecerf G, Fessy MH, Philippot R, Massin P, Giraud F, et al. Femoral offset: anatom-
ical concept, definition, assessment, implications for preoperative templating
and hip arthroplasty. Orthop Traumatol Surg Res 2009;95:210–9.
[41] Young EY, Gebhart J, Cooperman D, Ahn NU. Are the left and right proximal
femurs symmetric? Clin Orthop Relat Res 2013;471:1593–601.

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case-control study. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.020