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A Review Of Activity Scores In Patients Aged Sixty-Five Or Less Undergoing Total Hip Replacement Versus Hip Resurfacing

Graeme S. Carlile1, Martyn Porter2

1Royal Cornwall Hospital, Truro, Cornwall, United Kingdom, TR1 3LJ.

2Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire, United Kingdom, WN6 9EP.

Address for Correspondence:

Graeme S. Carlile
Specialty Training Registrar, Trauma & Orthopaedics
Royal Cornwall Hospital, Truro, Cornwall, TR1 3LJ.

Phone:  07977299952


Choice of implant for patients aged sixty-five years or younger requiring hip arthroplasty is a topic of current debate. Those in favor of resurfacing maintain it offers greater range of motion and hence activity. In this study, we reviewed the Oxford Hip Score’s (OHS) and Duke Activity Score’s of patients that had undergone either total hip replacement (THR) using an Elite Plus Stem, or hip resurfacing using a Birmingham Hip Resurfacing (BHR).

The THR cohort comprised 34 implants (4 bilateral), 17 men and 17 women, mean age 56.08 years. The resurfacing cohort comprised 27 implants (3 bilateral), 18 men and 9 women, mean age 50.51 years. The mean difference calculated between pre- and post-op OHS was 25.33 and 22.08 for the THR and resurfacing cohorts respectively. The mean Duke score was 42.3 and 53 for the cohorts respectively.

Using the pre-operative and post-operative change in the Oxford Hip Scores, no statistically significant difference was found between the THR and resurfacing cohorts using a two-sided Mann-Whitney U Test (p = 0.2891). There was a statistically difference found between the THR and resurfacing cohorts with regards to activity using post-operative Duke scores, (p = 0.0047).

This study has emphasized the use of hip scores. In terms of reducing pain, both prostheses appear equally effective. With regards to activity the resurfacing cohort faired better. Our study suggests at one year post-op, younger patients with a resurfacing have a greater activity level than those with a THR.

J.Orthopaedics 2009;6(4)e8


Total hip replacement; Total hip resurfacing; Activity; Duke Activity Status Index



The choice of hip implant for young active patients is currently controversial, with no clear concensus1. Survivorship analysis varies for each prosthesis, 84% survival at 15 years for young patients using an Exeter Universal/Exeter All-poly prosthesis2, to 99.8% survival at 8 years using a Birmingham Hip Resurfacing3. The debate regarding survivorship will continue until comparative long-term results are published. In addition to survivorship, it has been highlighted that we must also consider activity levels in this debate4. To date, few studies have directly examined activity levels in younger patients undergoing total hip arthroplasty versus resurfacing. With reference to patients’ aged 55 of less undergoing resurfacing, McMinn3 stated 97.6% of patients went on to lead “an active lifestyle” following surgery. The proposed greater level of activity and return to a normal lifestyle in patients whom undergo resurfacing, is an argument that has gained weight with clinicians in favor and those that market resurfacings5. In this study we reviewed the pre- and postoperative hip scores of patients aged sixty-five or less undergoing total hip replacement (THR) or hip resurfacing.

Materials and Methods:

All patients undergoing primary hip arthroplasty at our institution were routinely asked to complete an Oxford Hip Score (OHS) preoperatively and at subsequent follow-up to measure the outcome of surgery6. The Oxford Hip Score is one of the most widely accepted and commonly used scoring systems in hip surgery. In addition to the OHS, we asked patients to complete a pure activity score at one year, in the form of the Duke Activity Status Index. Five of the twelve questions comprising the OHS deal with pain and the remainder, activities of daily living. All patients that had completed a pre-operative and 1 year post-operative OHS were asked to complete the Duke Activity Status Index (DASI). The DASI was developed in 1989 to accurately measure functional capacity of patients undergoing exercise testing by the Department of Medicine, Duke University Medical Centre7 (Duke University Medical Centre, Durham, North Carolina, 27710). The Duke Activity Status Index consists of twelve short questions regarding levels of activity (table 1). The maximum score is 58.2 and minimum score is 0. Points are awarded depending on the difficulty level of the activity; for example, running scores 8 points, walking 1.75.



1.     Can you take care of yourself (eating, dressing, bathing, or using the toilet)?

Yes – 2.75

No – 0

2.     Can you walk indoors, such as around your house?


Yes – 1.75

No – 0

3.     Can you walk a block or two on level ground?

Yes – 2.75

No – 0

4.     Can you climb a flight of stairs or walk up a hill?

Yes – 5.5

No – 0

5.     Can you run a short distance?

Yes – 8

No – 0 

6.     Can you do light work around the house, such as dusting or light washing?

Yes – 2.7

No – 0

7.     Can you do moderate work around the house such as vacuuming, sweeping floors or carrying in groceries?

Yes – 3.5

No – 0

8.     Can you do heavy work around the house, such as scrubbing floors or lifting and moving heavy furniture?

Yes – 8

No – 0

9.     Can you do yard work such as raking leaves, weeding or pushing a power?

Yes – 4.5

No – 0

10.  Can you have sexual relations?

Yes – 5.25

No – 0

11.  Can you participate in moderate recreational activities like golf, bowling, dancing, doubles tennis or throwing a baseball or football?

Yes – 6

No – 0 

12.  Can you participate in strenuous sports such as swimming, singles tennis, football, basketball or skiing?

Yes – 7.5

No – 0



Table 1:  The Duke Activity Status Index

Population & Sample

The clinical details of the patients comprising the THR & resurfacing cohorts are given in table 2. Of the 182 patients in the THR cohort group, sadly 4 (2%) patients had died since surgery, 2 (1%) patients had been revised for deep infection and 3 (1.6%) patients had moved outside of the health authority. Of the 90 patients in the BHR group, all patients were alive at the time of study, but 2 (2%) patients were excluded for deep infection, 2 (2%) patients had moved outside of the health authority and 1 (1%) patient was revised due to aseptic loosening. At the time of study, no patient from either group had reported any episode of dislocation.

Both the OHS and DASI assign a numerical value to each question. Values were combined and a total for each questionnaire was calculated separately, and recorded. When reviewing the very first returned questionnaires, it was apparent that controls were needed regarding how totals were calculated. In particular, question 10 of the DASI; “Can you have sexual relations?” Many patients chose not to answer this question because they felt it too personal; they were widowed or could not have intercourse for another medical reason, e.g. impotence. Given the age of patients involved in the study, it is not surprising that this occurred. Additionally, some patients answered both ‘Yes and No’ to questions. This did not follow any apparent pattern and occurred solely within the Duke responses. It was decided that for these ambiguous answers a “worst case scenario” would be assumed, and subsequently the scoring for that question was marked as zero. This control ensured all totals were calculated in the same manner. Though it occurred much less when calculating the OHS totals, the same controls were applied.


Elite Plus


Total number of prosthesis implanted



Total number of patients



Bilateral arthroplasties (%)

9 (5)

4 (4)

Gender (%)




79 (43)

70 (77)



103 (57)

20 (23)

Total Number of Pre-Op OHS’s completed (%)

161 (88)

68 (75)

Total Number of Pre-Op OHS’s completed (%)

49 (30)

28 (41)

Total Number of Duke Scores completed (%)


34 (69)

27 (95)

Total number of remaining patients



Bilateral arthroplasties (%)

4 (12)

3 (11)

Gender (%)




17 (50)

18 (66)



17 (50)

9 ( 34)

Mean age in years (range)

56.08 (30 to 65)

50.51 (30 to 65)

Diagnosis (%)




24 (71)

26 (96)


3 (8)



3 (8)

1 (4)


2 (6)



1 (3)



1 (3)


Table 2:  Clinical details of the patients comprising THR & resurfacing cohorts.


Results :

In the resurfacing cohort, the mean age range in years was 50.51 (30 to 65) and comprised 18 men and 9 women. The pre-operative Oxford Hip Score had a median value of 44 (27 to 48) and a mean of 35.81; post-operatively a median value of 16 (12 to 36) and a mean of 17.29; the difference between them both (pre-op minus post-op) had a median value of 23 (12 to 42) and a mean of 25.33. The total DASI for the questionnaire had a median value of 58.2 (32.2 to 58.2) and had a mean of 53.

In the THR, the mean age range in years was 56.08 (30 to 65) and comprised 17 men and 17 women. The pre-operative Oxford Hip Score had a median value of 44 (29 to 57) and a mean of 43.79; post-operatively a median value of 18 (12 to 55) and a mean of 21.70; the difference between them both (pre-op minus post-op) had a median value of 24.5 (2 to 27) and a mean of 22.08. The total DASI for the questionnaire had a median value of 48.1 (5.45 to 58.2) and had a mean of 42.3.

Statistical Analysis

The Mann-Whitney U Test was used to analyse the data, chosen because of the unequal number of patients in each cohort, and because both comprised a small number of patients. Initially the test was used to compare the pre-op resurfacing OHS results with the pre-op THR OHS results, and the post-op resurfacing OHS results with the post-op THR OHS results. This was to ensure that there was no statistically significant relationship present, which would suggest we were comparing different cohorts. The results, using a two sided Mann-Whitney U Test were 0.3413 (95% CI –6 to 2) and 0.1606 (95% CI –6 to 1) for the pre-op and post-op results respectively. As neither were shown to be statistically significant at the 95% confidence interval, then it was possible to assume that statistically, the cohorts were not different, and were in fact similar. The Mann-Whitney U Test was used again, to look for a statistically significant relationship between the differences produced by subtracting the pre-op OHS result from the post-op OHS result, in the resurfacing and THR cohorts. The result using a two-sided test of 0.2891 (95% CI –2 to 7), demonstrated that there was no statistically significant difference between the two sets of results. Finally, the Mann-Whitney U Test was used again to look for a statistically significant relationship between the DASI scores of the resurfacing and THR cohorts. The result using a two-sided test of 0.0047 (95% CI 0 to 15.5), demonstrated that there was a statistically significant difference between the two sets of results.

Discussion :

Pollard et al8, found that when comparing 51 hybrid THR’s at an average follow-up of 80 months versus 53 BHR’s at an average follow-up of 61 months, there was again no statistically significant difference between mean OHS, but the BHR cohort had a significantly greater level of activity using the University of California at Los Angeles (UCLA) activity score9. Amstutz et al10 also found a statistically significant greater level of activity when comparing 100 Tharies resurfacings with 100 Trapezoidal-28 THR’s.

This study has a number of limitations. Firstly this is a retrospective review of the hip scores obtained over a number of years. Patients selected to undergo a resurfacing procedure were not prospectively randomised into a ‘resurfacing treatment arm’. Therefore they underwent the procedure as they either requested it themselves because they felt they were ‘personally active’, or were perceived by the surgeon as being a good candidate. This is evidenced by the mean pre-operative OHS of 35.81 in the resurfacing cohort, versus 43.79 in the THR cohort. The DASI score, which was introduced post-operatively, was not used pre-operatively and therefore we cannot conclude if both cohorts were well matched in terms of pre-operative activity. Whilst this study has focused on patients below sixty-five, with a good age range in each cohort, the resurfacing cohort were younger, with a mean age of 50.51 years versus 56.08. The follow-up period of one year is also much shorter than in similar papers.

From this review we can conclude that using the Duke Activity Status Index as a measure of function, for those patients undergoing a hip resurfacing, at one year had a greater level of activity than those whom underwent THR. In this study there was no statistically significant difference at one year post-op found between either cohort using the OHS. This may be a reflection of the questions utilised by the OHS, six of which focus upon pain. Both prosthesis appear to be as effective in reducing pain, as one would expect. Without the benefit of using a pure activity score in addition to the OHS, one may incorrectly conclude that this is also true of activity. The additional use of a pure activity score cannot be over stressed. This study has highlighted the use of hip scores in assessing patients and in particular the use of a dedicated activity score. The DASI score is quick to implement and complete. It takes into account many of the everyday activities that patients will perform. The results obtained through it use are in keeping with the established literature. The DASI score could be used to assess activity in further areas of orthopaedic research and should be a consideration.

Reference :

  1. Mundy GM, Esler CAN, Harper WM. Primary hip replacement in young osteoarthritic patients: current practises in one UK region. Hip 2005; 15: 159-65.

  2. K. Mäkelä, A. Eskelinen, P. Pulkkinen, P. Paavolainen, and V. Remes.
    Cemented total hip replacement for primary osteoarthritis in patients aged 55 years or older: RESULTS OF THE 12 MOST COMMON CEMENTED IMPLANTS FOLLOWED FOR 25 YEARS IN THE FINNISH ARTHROPLASTY REGISTER. J Bone Joint Surg Br, Dec 2008; 90-B: 1562 - 1569.

  3. J. Daniel, P. B. Pynsent, and D. J. W. McMinn. Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis. J Bone Joint Surg Br, Mar 2004; 86-B: 177 - 184.

  4. Frederick J. Dorey and Harlan C. Amstutz. The Need to Account for Patient Activity When Evaluating the Results of Total Hip Arthroplasty with Survivorship Analysis. J. Bone Joint Surg. Am., May 2002; 84: 709 - 710.

  5. Corin Group PLC. (accsessed on 2nd February 2009).

  6. P. B. Pynsent, D. J. Adams, and S. P. Disney. The Oxford hip and knee outcome questionnaires for arthroplasty: OUTCOMES AND STANDARDS FOR SURGICAL AUDIT. J Bone Joint Surg Br, Feb 2005; 87-B: 241 - 248.

  7. Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Pryor DB. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989 Sep 15;64(10):651-4.

  8. T. C. B. Pollard, R. P. Baker, S. J. Eastaugh-Waring, and G. C. Bannister. 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. J Bone Joint Surg Br, May 2006; 88-B: 592 - 600.

  9. CA Zahiri, TP Schmalzried, ES Szuszczewicz, and HC Amstutz. Assessing activity in joint replacement patients. J Arthroplasty, Dec 1998; 13(8): 890-5.

  10. HC Amstutz, BJ Thomas, R Jinnah, W Kim, T Grogan, and C Yale. Treatment of primary osteoarthritis of the hip. A comparison of total joint and surface replacement arthroplasty. J. Bone Joint Surg. Am., Feb 1984; 66: 228 - 241.

This is a peer reviewed paper 

Please cite as: Graeme S. Carlile: A Review Of Activity Scores In Patients Aged Sixty-Five Or Less Undergoing Total Hip Replacement Versus Hip Resurfacing.

J.Orthopaedics 2009;6(4)e8





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