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Hip Resurfacing Bilateral BHR, Need advice

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Bioguy501

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Thank you @Eman85. (yes, Jaycey... it was a good post) I always try to glean one nugget of information from any post. Your nugget @Eman85 was when you said your doctor said "no cleats" and do not stick your foot in the ground and rotate. Well... that is exactly what happens in golf, especially with a good swing. You wear cleats... and at the end of a golf swing (if your are right handed), you shoulders will be facing the target... but your left foot is planted in the ground (with soft spike cleats) facing perpendicular to your shoulders. That sure sounds like what your doctor is telling you NOT to do with a THR.

The post from @Mojo333 was also informative. Ed Su is considered one of the best BHR surgeons (out of NY) in the country. He trained with Dr. Callander out of San Francisco at HSS. Yes... there is a 1-2% risk of femoral neck fracture with BHR hip resurfacing (because there is a neck left after surgery). However, this usually occurs in the first 6 months for those that do not listen to their doctor and overdo it. Remember, BHR patients are usually younger and highly active. And they want to get back to that ASAP. But that is a mistake. You have to ease back into it. There is probably an equal chance (1-2%) of femoral fracture in THR surgery... but here is a key consideration. A fractured femoral NECK... is whole lot better than a fractured femur. Gary
 

Going4fun

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My sense is that golf is one of the least problematic activities for people to return to after hip replacement. There are plenty of people on this forum who returned to golf. And they seem to return to the activity much earlier than I could return to my activity: running.

I assumed I would have a resurfacing until I learned that there are plenty of well-known, famous, highly regarded total hip surgeons who don't think resurfacing provides any particular advantages. A growing number of surgeons, like mine, are comfortable with patients running, jumping, playing basketball, whatever. I have no restrictions, and my surgeon is chief of joint replacement for a nationally acclaimed practice.

I ultimately could not get comfortable with the metal on metal of resurfacing (though Pritchett has a device that I think uses cross-linked polyethylene) and the BHR founder himself, Derek McMinn also is now testing a cross-linked polyethylene resurfacing. McMinn found that over time more and more women were having problems with his BHR.

Total hip surgeons used to be worried about dislocation, and they have largely solved that problem. And they used to be worried about wear, but the wear rates of the ceramic on cross-linked polyethylene devices are proving to be astonishingly low. Two top surgeons said essentially "not zero wear, but almost zero wear" going on 12 or so years at the time, probably 15 years now.

I also sensed (and this may not be accurate but it was a sense) that SOME of the resurfacing folks (and this is not a hard core criticism, just a concern I had)--because they are going against the grain by staying with resurfacing and because they are going against the grain by staying with metal on metal--could be a bit slow to acknowledge metal problems among their patients. I also realized I wouldn't want to test myself for metal problems every two years, which is what resurfacing doctors seem to recommend.

I think you are on the right track in the names you mention. Had I opted for resurfacing, I would have chosen among 3 or 4 people. You want high-volume folks.

Bottom line: you should be able to return to golf after resurfacing or total hip ... Just do a search for "golf" and you'll see tons of people talking about going back out there after total hip replacement.
 

Celle

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@Bioguy501 - It seems you're favouring having a BHR.
Best wishes for it and do let us know how you get on, won't you?

Just for interest: In 2011, my Partial Knee Replacement (PKR) failed suddenly after 11 years. The plastic spacer between the two metal components had apparently worn thin and one day, as I was walking fast, it broke suddenly.
From being fully active, I was suddenly on the floor, in pain and completely unable to bear any weight on my leg.

I was on holiday in Canada and I had to get back to New Zealand, find a new surgeon (mine had retired) and book a date for a Revision to a Total Knee Replacement (TKR).

From the day of the PKR failure to my surgery, it was almost 3 months. During that time, I was partially weight-bearing, using two forearm crutches.

I had no symptoms of metallosis and yet my surgeon told me that at surgery he found the fluid in my medial knee compartment was bright green and all the visible soft tissue was black. The metal femoral and tibial components of my PKR had been rubbing on each other and metal flakes had been loose in my knee.

I had asked to be given the prosthesis that was removed at surgery and when I looked at it I could see scratches on both articulating surfaces, where the metal had been damaged.

I had, and still have no symptoms of metallosis and I have not had blood tests.

I now have a TKR in each knee and a Left Reverse Shoulder Replacement, all recoveries without complications.

At 79, I still drive, do all my own housework, shopping and gardening and, until Covid intervened, I have travelled from NZ to the UK and back every year for the past 7 years, to visit my daughter, who has settled in the UK. I hope to be travelling to the UK again next year.
 
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Bioguy501

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Great, thorough, informative post from @Going4fun Thank you for your time.

You mention that "they have largely solved the dislocation problem (for) THR." Can you explain how? The THR has a smaller ball compared to your natural hip... and this concerns me. That is why I would go with the anterior (rather than posterior) approach if I went with total hip over resurfacing.

I agree that there is a growing trend amongst THR surgeons to say to their patients... after an appropriate amount of healing time, do whatever activity you want on that new total hip. Dr. Scott Ball out of UCSD, a highly regarded hip surgeon, said he would get the new total hip with the highly crosslinked poly instead of resurfacing for himself... and I believe he is a year or two younger than me (age 56). He said he would have no problem being active and surfing on the new total hip implant.

But... what if you needed a replacement in both hips???

And I also agree... that the new highly cross-linked poly is very good. It show VERY little wear after 15 years. But I'm 56... and my Dad is still alive at 87!!! With even more technology on its way, I might get into my 90s. Can this poly last 30... or even 40 years? Maybe a 50-60% chance to last that long. And I will have two implants! I do not want to have to go through one or two more hip replacements in my late 70s or 80s. And the revision total hip replacement is more difficult. Given my age, my logic is this: 95% or more of all large boned men have still have their BHR after 15 years. Of the 5% that do not, surgeon error was probably the cause... and it typically causes problems in the first 5 years. Once you get to the 15 year mark with that BHR, what could go wrong? It is NOT going to wear out. The cup had bone grow right into it, so that is not going to move. The cement for the BHR cap has proven to NOT be a weak link... even Dr. Thomas Gross admits this... and yet he still goes cementless with his design. (Biomet).

We do not have data past the 20 year mark with the highly cross-linked poly. Will it start to break down after this point? Will it oxidize? As an anatomy instructor, one of my favorite expressions is this "You do not age linearly... you age exponentially." Will the new poly liner do this too? Hard to say... I sincerely hope not for the benefit of my wonderful fellow human beings.

Keep in mind, the main problem with the THR is not the poly liner... it is the aseptic loosening of the stem down the femur... which makes perfect sense from an anatomical and physics perspective. As we get older, bone remodeling is slower. Osteoclasts start winning the war against osteoblasts. (Sorry for the anatomy-speak) Also... the THR has a MUCH higher dislocation rate compared to the BHR.

I welcome all comments. Gary
 

Going4fun

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The aseptic loosening largely occurred because the liner would wear down and little particles would fall out into bone. That's not happening with this new generation of hips with the cross-linked polyethylene.

So in the previous hips, wear would already be taking place at 15 years ... so far, almost no wear with this new generation ... no guarantees to last a lifetime ... but the signs are great for lasting a good long time. Surgeons are cautious: joint replacement surgeons have been burnt many times when thinking there was a breakthrough (like metal on metal total hips, which became a disaster) ... but so far they don't see problems happening with the new hips. BTW: Gross and Pritchett are using new devices. There isn't a 20-year track record on those devices either. McMinn is one of the few people whose patients (his BHR) have gone that long .... You can go to Gross' site and see that the data he has for his current device is 13 years .... (I think Su is outstanding and might have gone to him for resurfacing, but when I last checked, he basically doesn't take insurance. It's like 20K out of pocket.)

So you will rarely hear surgeons say "I guarantee this device will last forever." But one reason surgeons are now comfortable with running is that they are pretty confident the devices will hold up. My surgeon will publicly say the data is at about 15 years ... in the office, his nurse will say she thinks the device will last 30 to 35 years ... really, my sense is I won't need a replacement and I'm planning on living healthily into my 90's!

How did surgeons solve the dislocation problem? Again, I'm not a surgeon, so this is a rough overview ... .Multiple ways ... My surgeon cuts from the front and side (anterolateral) and the dislocation rates with that method are low because the muscles or tissue cut aren't the key muscles that keep the device in place. (Peter Brooks uses the anterolateral approach with his BHR's.) The anterior (front) approach, which is increasingly popular these days, also extremely low dislocation rates ... Meanwhile the posterior approach surgeons started to do what they call "soft tissue repair." Somehow they tied up the tissue after inserting the implant to firm up things so that the device wouldn't slip out of place. It was the posterior approach that I think was most vulnerable to dislocations. So the worry about dislocation with posterior approach surgeons--I think that's out of date. Surgeons have been publishing on "soft tissue repair" for a lot of years now.

My cliff notes version of the story is that total hip surgeons kept making incremental improvements to fix problems ... and over years, these improvements added up ... and the manufacturers created this incredibly durable cross-linked polyethylene ... and then kept improving on that ... so it all added up to surgeons losing interest in resurfacing. They basically fixed the problems resurfacing was designed to solve. The total hip surgeons aren't idiots for losing interest in resurfacing.

Oh, my right hip will need to be done some day ... within probably 5 to 10 years. I'll not blink at getting another total hip done. So yes, getting a bilateral, I'd absolutely get total hips. The improvements they are making ... by the time you might need a revision, revisions would have been improved and many current revisions are excellent! BTW: there's another myth out there (to my mind) that converting a failed BHR to a total hip is simple and easy. No so, say a number of revision surgeons.

I just thought resurfacing was more risky ... whereas the total hips keep improving with the experience of thousands of surgeons making incremental improvements year after year.

Scott Ball's comment to my mind is extremely revealing.
 
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Eman85

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@Bioguy501 You say you know anatomy. To do a THR they cut a hole and dislocate you and rotate the femur in whatever direction they make the hole. In my case posterior, my OS's choice, so they turned my femur to the rear and out. Needless to say my muscles had go along for the ride and stretch in ways they had never experienced. This opening of the hip capsule and stretching of the muscles is what makes a person susceptible to dislocation. Because of my direction that they rotated that is why I was told to follow restrictions for 6 weeks just to get the basic healing and get the muscles strong enough to hold it together for normal life strain. Somewhere on this board there is a chart that shows the time graph for dislocation risk.
I was holding a replacement hip in my hand at 30 years old and had my first THR at 62. I had pain from the time I was a teen as I had SFCE and had pins inserted in my femur. I waited for a lot of reasons but one of the main reasons was I could do anything with my original hips despite ,limited ROM. I didn't want to have THR's and then have it done again. My choice, everyone has different ways of looking at it. I have no regrets in waiting or having it done.
 

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It is a tough decision and one I wrestled with. I ended up going with dual mobility THR. I know my personality and wondering if I would be one of the unlucky few dealing with metallosis concerned me.
You also have to question the source and data. The joint registries show a better long term rate for THR with ceramic on cross linked poly than BHR. Now, what that doesn't account for is activity level. From my research the BHR recovery can be harder as more access is needed due to the head of femur not being removed. And while it is bone sparing on the femur side it can be less so on the acetabular side to the need for a larger cup. My 65 year old neighbor had BHR done by Pritchett and is back to regularly playing tennis. I think Eman said it best, find the best surgeon/craftsman for your hip/piece of oak. Both will likely serve you well and each have risks. It can be a difficult process to decide. Wishing you peace as you work through it.
 

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Keep in mind, the main problem with the THR is not the poly liner... it is the aseptic loosening of the stem down the femur... which makes perfect sense from an anatomical and physics perspective. As we get older, bone remodeling is slower.

I welcome all comments. Gary
Where did you find this information? That is not my recollection although I haven't looked at the recent registries.
 

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I'm following along and find this thread very interesting... especially that it comes from an anatomy instructor. I don't have much relevant input at this point, but really wanted to say thank you Mr. Bioguy501 for creating an informative discussion, as I'm learning myself, and others very likely are as well.
So many variables in the human body and how it works it's mind blowing.
Mr. Gary, I sincerely hope you get the relief you're after along with the performance factors and longevity you need.
We're all in this for the same goal bottom line, which is to have a pain free healthy life for ourselves and everyone that cares about us... at whatever physical level we're accustomed to.
 
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Bioguy501

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@dapplega Here is the latest from the Aussie Joint Registry:
Revision rate.JPG

As you can see from the above data taken directly from the 2020 report, as of 2019... 15.2% of all people that got hip resurfacing at 19 years had a revision. For the THR, it is 12.2% at 19 years. To most people, it would seem from this data that resurfacing is worse compared to THR. But here is where you have to analyze the data carefully, because the above information is not factoring in a lot of variables. Over the last 19 years, there were many types of hip resurfacing implants... and virtually all of them were recalled within the last 10 years...except the BHR. So there is 10 years of data from bad devices in the early years negatively affecting the revision rate of hip resurfacing. (Yes... this would be the case to some degree with total hip implants... but the affect would not be as dramatic). Another key variable is that people with hip resurfacing are younger and more active. That is why they get hip resurfacing. A better comparison would be to separate the data so that the same age range is compared. (I used to have that data somewhere). When you compare apples to apples, hip resurfacing has a lower revision rate. Perhaps the biggest variable in the data is that 19 years ago, many hip surgeons were just learning how to do hip resurfacing. Whereas the THR is definitely taught in med school for all hip surgeons, but not putting in a BHR. And finally, the most important variable is surgeon experience. If you look at the data from Dr. Su, Gross, Pritchett, Brooks, (obviously McMinn) and other high volume hip resurfacing surgeons, their revision rates are exceeding low and much better than the THR revision rate... where EVERY THR surgeon is pretty much a high volume surgeon.

I should point out that another key consideration is that the re-revision rate (which means getting a 2nd revision - or 3rd overall hip implant) is much lower for BHR patients who get a first THR. If you have to revise a BHR, a THR performed at the time of the 1st revision has the lowest cumulative percent 2nd revision of 15.5% at 10 years... whereas the 2nd revision rate for the THR (thus... THR original to THR 1st revision to THR 2nd revision) is 27%... nearly 12 percent higher. Gary
 

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So which resurfacing person are you leaning towards?
 

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Thanks for the data and your perspective.
I'll add my perspective from the other side. 19 years of data is just the beginning of the use of highly cross linked poly so it is anticipated those numbers will continue to stay low. Just like resurfacing devices, there were a number of metal on metal hip implants that could also sway the data. Now, I thought the registries did their best to remove these from their data. If so, would assume it would be applied to both resurfacing and replacement data.
I do agree the activity levels would be good to better understand. After all, that is one of the main selling points of resurfacing yet I have seen no data to actually confirm the assertion that resurfacing recipients are more active.
As I said, the tipping for me was the unknown about metallosis. It is a small risk but enough to sway me.
You need to follow your heart and gut with your choice.
The right solution is the one you feel best about.
 
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Bioguy501

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At this point, I am scheduled with Dr. Callander in San Francisco this September for a BHR. Great reviews of this doctor and many of them. He has done way over 1000 BHR surgeries. Plus, when he called me at my home (yes, this doctor makes house calls) I mentioned Dr. Su in conversation... and he said, "Oh, Ed, great doctor. He trained under me at HSS (Hospital for Special Surgery) when I was chief surgeon there."

I was already leaning toward him, but that sealed the deal. The well known Dr. Su trained under Dr. Callander... and Dr. Callander was one of the first in the U.S. to learn directly from the BHR guru himself... Derek McMinn of Birmingham, England.
 

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That's awesome! A plan and direction is always good.
I hope you get on the surgery registry on this site, and let us know how you're doing, pre-op and post-op.. definitely... please.
Even though some of us have made other choices and are doing well, your information is priceless... and could very well help someone else.
I'll look forward to reading your journey and I'm hoping great things for you.
You seem to have very little fear, and are approaching it with your eyes wide open.
This will be interesting to many of us.
Thank you for sharing here.
 

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@Bioguy501
I have updated your signature to reflect you are having a BHR, if you would like another thread title just post it here and a moderator will update it for you.
All the best with your upcoming surgery, you have done your research and have picked the best approach for you!
 

Celle

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@Bioguy501 , do you have a specific date yet for your BHR? If you let us know when it is, we'll add the date to your signature.
 
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Scheduled for Sept. 2021 (Dr. Callander)... not sure if I go with the left or right at this point. Both are bad.
 

Eman85

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@Bioguy501 You obviously have done your research including finding your OS. It does look like BHR might be a very good choice for you. I hope you follow up with a recovery thread, there aren't many resurfacing threads. It would be interesting and good info for others considering having that choice.
 
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Bioguy501

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I was doing some more research as my operation is getting closer. I like to use PubMed to look at articles. I came across this one which claims it was the largest study to compare the BHR hip resurfacing implant to cementless THR... in 55 year old people and younger. It is pretty eye-opening. Here is the link if you want to read everything, and check the context of the content: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6224684/

Here is a key table in the article that summarizes the content in the article:
BHR vs THR.JPG

So for you young guys like me, this evidence is hard to ignore. Keep in mind this data is from experienced surgeons in hip resurfacing. Peter Brooks, out of Ohio, is one these doctors... and is involved in this study.
 

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