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Hip Resurfacing Arthroplasty (RA) White Paper

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boivette

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Hip resurfacing arthroplasty (RA) is a surgical technique in which the surface of the femoral head is covered with a metal cap. Initially, only the femoral side was addressed, but because metal articulating against cartilage frequently causes pain, surgeons introduced an acetabular component as early as the 1960’s. These components were less successful than low-friction total hip replacement (THA). As such hip resurfacing never gained the same level of popularity and success as the more traditional total hip replacement.

With improved understanding of lubrication mechanisms and improved manufacturing techniques, metal-on-metal hip resurfacing re-emerged as a viable treatment alternative in the early to mid 1990’s. The theoretical advantages of this type of hip replacement are: less bone removal from the femoral side, a larger diameter articulating ball, more stability (and a lower dislocation incidence), simpler surgery when revision of the components is needed, and what patients describe as “a more normal feeling” hip. Also, the metal-on-metal articulation has the same advantage of other metal-on-metal bearings, namely reduced wear. Theoretical disadvantages include: more difficult surgical technique, equal or more bone removal on the acetabular side, lack of supplemental acetabular fixation besides the initial press-fit in most systems, femoral neck fracture, higher metal ion exposure from the the metal-on-metal articulation, and femoral head avascular necrosis/collapse leading to femoral component failure.

Despite conflicting claims from proponents and skeptics, the state of the current data is inconclusive to determine whether hip resurfacing is superior (or even equal) to total hip replacement. For example, Lavigne et al (1), Mont et al (2) and Naal et al (3) have recently reported higher activity levels in RA patients compared to THA patients. However, in all these studies, the RA patients started with a higher functional activity level. Le Duff et al (4) reported that RA implants had a higher survival rate in obsess patients specifically because they were less active than THA patients. Shimmin et al (5) found no difference in gait analysis between RA and THA patients. The Australian hip resurfacing registry (6) includes data on over 10,000 RA procedures. The revision rate, compared to THA, was higher in women, men over age 65, and patients with avascular necrosis, inflammatory arthritis (such as rheumatoid arthritis) and dysplasia of the hip. Only men under 65 demonstrated equal revision rates when comparing THA to RA.

As of late 2008, RA represents another treatment option for patients with hip disease. As always, the decision for undergoing RA or THA should be undertaken after a thorough discussion with your surgeon. Neither THA nor RA is the correct choice for ALL patients. Lastly, choose a surgeon with extensive experience in perfoming RA.

References:
1. Lavigne et al, Rev Chir Orthop Reparatrice Appar Mot. 2008; 94(4): 361-367.
2. Mont et al, Clin Orthop Relat Res. 2008 Epub.
3. Naal et al, Am J Sports Med. 2007; 35(5):705-11.
4. Le Duff et al, JBJS (A) 2007;89:2705-2711.
5. Shimmin et al, J Bone Joint Surg Am. 2008; 90(3): 637-654.
6. Buergi ML and Walter WL, J. Arthroplasty, 2007; 22(7), Supp. 3: 61-65.
 

Josephine

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Excellent report - thank you admins!
 

BigDog Mom

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" The Australian hip resurfacing registry (6) includes data on over 10,000 RA procedures. The revision rate, compared to THA, was higher in women, men over age 65, and patients with avascular necrosis, inflammatory arthritis (such as rheumatoid arthritis) and dysplasia of the hip. Only men under 65 demonstrated equal revision rates when comparing THA to RA. "

Thank you for this article. Before my operation I really did research RA quite thoroughly and came to a similar conclusion - I was just uncomfortable with the number of "comparatively early" revision stories I came across. Being female with joints that were really a mess because of HD. On the other hand I do admire the women who have made this choice because it will further improvement and study.

Donna
 

JudyS

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thanks that was a great article. I was all for resurfacing until I spoke at length with my surgeon about it. He came up with similar points and I already knew I had osteopenia.
For me the THR was the best choice.
Judy
 

Josephine

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Don't forget to vote!
 

UTdave

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Helpful article. I almost got a RA despite the fact that all the Ortho's I spoke with (4) felt this was not superior to metal-metal THA. I finally pinned my surgeon down as to why and he told me about femoral neck fracture. I found an article by Landis' surgeon suggesting very high femoral neck fracture rate in dysplasia patients - which I am one.

As a physician myself, you'd think I'd be able to objectively look at the data and come to the same conclusion as the article above, however, there is a psychological component of losing bone that is hard to get over. Bottom line is get a good surgeon, discuss your expectations for post-op and likely they know the best choice for you. We'll see next year when I start pushing the activity hard. . .
 

cdnlager24

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An Interesting article, and with all surgeries there is always a risk that it won't work. I myself and getting ready for a hip resurfacing on the 19th of Nov 2008. I have AVN (Avascular Necrosis). I am a 38 year old male in the United States Army, so I am very active. A lot of journals and articles I have read imply that it is best to wait to do a THR at my age if possible, as they like to do them at a later age.

I took this information right off the BoneSmart home page..

Hip Resurfacing Option
To Conserve As Much Bone As Possible
CONSERVE® Implant
Partial Resurfacing
(Wright Medical)
For younger patients, a total hip replacement may not be the best solution for their hip pain because it can mean difficult and numerous revisions later in life. Hip resurfacing, however, leaves more of the bone in place, giving these patients more time before a total hip replacement becomes necessary.

Partial hip resurfacing, or hemi-resurfacing, is the most bone-conserving approach to hip surgery. During this procedure, only the femoral head (where the leg joins the hip) is reshaped and resurfaced. The hip socket (acetabulum) is left completely intact. The obvious benefit with partial resurfacing is that the patient keeps most of his or her own bone, which allows for easier revisions in the future (if one becomes necessary).



So, obviously everyone is different and heals differently. But if you are in good shape and active, I would consider this option. I will keep you all posted on my progress and recovery.

Also, there are some other great forums out there to help educate yourself on the pros and cons. As I mentioned, there are pros and cons to every surgery. Yahoo.com has come great forums that I peak at from time to time. somewhere else is one and for thos of you that have AVN as myself, here is another great yahoo forum...avnsupportgroupinternational.

I wish you all the best and will keep you posted...

Daniel
 

KarenMG

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I am a 43 year old woman who had been extremely active prior to my OA descent. I missed the activities I previously enjoyed like skiing, cycling, working out, pilates and yoga. I had a hip resurfacing done in late August. I am thrilled with my early results. I'm already back to recumbent bicycling, pilates and light yoga. (At only 10 weeks post operation) And I don't have any restrictions, which was important to me. I cannot express just how happy I am that I did the "legwork" (OK, the pun was intended) to make sure I made the right choice based on my age and goals. I am without any pain, and am working on stretching to regain my range of motion. This surgery has been miraculous for me.

I'd done extensive research, and was aware of the higher revision rate for resurfacing among petite women compared to THR. I am 4'11" so that was certainly a concern for me. My mother had two THR's, so while I've seen how wonderful the results can be to relieve pain, I was told by doctors that I was not an ideal candidate yet because I was so young and because of the activities I wanted to resume after surgery.

I'm so glad that your article mentioned "Lastly, choose a surgeon with extensive experience in perfoming RA." Thanks for mentioning that key point. That was the very most important tip I learned. Because this procedure is new, especially in the United States, there aren't many experienced surgeons who perform resurfacing (compared to THR's). And according to the Rush study, most of the complications occur with surgeons who are newer to the procedure. So do not be one of your doctor's early surgeries!! Anyone considering resurfacing should do extensive research and find a physician who has performed several hundred surgeries at a minimum. Even better if the surgeon has performed more than 500 surgeries. Experience truly counts when it comes to the hip resurfacing option.

Thanks for the thread!!

KarenMG
 

Josephine

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That has aways been my mantra when addressing the issue of choosing procedure, prosthesis or surgeon. To quote from my sticky How to choose a surgeon and a prosthesis in the two main pre-surgery forums



My advice is this. Choose your surgeon carefully. Ask him these questions

1. how long have you used your prosthesis of choice?
2. how many do you do each year (anything over 500 is good)
3. What is your infection rate (anything 1-0.5% is good)
4. what is your incidence of short term complications (dislocations, wound infections)
5. what is your incidence of long term complications (infections, loosenings, breakages of prosthesis)

Any surgeon worth his salt will not only be pleased to discuss these but will have the figures ready to hand. Any hint of reluctance, offense or waffle, go find yourself another surgeon!





I think no other issue is as important as this.
 

Michael

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The article is not comparing apples to apples. Most people who have the Resurfacing procedure are younger and more active as Mont has stated. Also, the procedure is alittle more difficult for the doctors as stated BUT once learned and properly trained, the surgeon will not even consider this an issue. One of the reasons for the U.S. results of failures is because of the doctors lack of experience and training. When a competent doctor is trained, the results ARE and failure rate are better than THR. Check out the European sites and their data on resurfacing. Over 14 years and less failures. Go to Derek McMinn and Ronan Treacy or Dr. DeSmet websites and get their failure rates.

I work in a facility with over 15000 people and I see people limping because of hip issues. There are five people who have had hip surfacing at our facility and they are all very active. I know seven others with THR and they are not active because their doctors told them that the can not. I mean they can't bend pass 90, cross their legs, while the others are at the employers gym doing what I just metioned, plus running. The people with the THR feel bad the they cannot participate in the state of the art work facility because their doctors could not recommend them to any physical exertion on their THR.

Look at Bo Jackson. Remember him? Pro football and baseball player who received a THR. He work out his first him in one year. Image if he had a BHR. He could of extended his career for years. I think he's on his third replacement.

That is why the doctors told me, and they will tell you if you are under 60 to WAIT until the pain is at a level 10 before getting a THR.

I'm getting my BHR next year. I'll be the sixth guy at work with one and a person who will continue to work out and run in our facility.

Please do your research. You can start here, but please finish your research at other sites.
Thank You,
Mike
 

Laeticiajane

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I was 37 when I had both my hips resurfaced at Oswestry. I was bone-on-bone, cysts, osophytes and severe fixed flexion, had no ROM at all in either hip and walked with a stick full time.

Nine weeks post op I was back riding my horse like I had never had a problem, I could mount from the ground.

Four years on I have just got better and better, still ride all the time, I can run should I need to - did a sports relief mile but I will never be a runner (haha), I can swim, I cycle... I just get on with my life. I can sit down and get out of a chair without even thinking about it.... life is normal and I have no restrictions.

For me as a young woman who spent several years in pain, hobbling whilst waiting while everyone else went walking, cycling etc... this was the best thing I ever did.

I chose an excellent surgeon (my treatment was on NHS) and researched beforehand. I didn't want to loose healthy bone or have a stem rammed down my femur until it is totally necessary. One day my hips will fail and I will get thr, but I have put off thr (and at least one revision) for so far, four years... who knows... but I am very glad with what I did.
 

fishwoman139

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Hi All - I just celebrated my 2nd anniversary of resurfacing on my left hip, and my right hip resurfacing is 2 1/2 year old. I couldn't be more thrilled with the results. Both my surgeries went very smooth and I've had no complications. I was 55 at the time. Before my resurfacing, I could barely walk. Now I've got my life back. I went to a very experienced resurfacing doc in Columbia, South Carolina, Dr. Thomas Gross. Most of his resurfacing patients travel to him for this surgery. If I had it to do all over again, I wouldn't do anything differently.
I'm doing a lot of yoga and have gotten my flexibility back - no restrictions. I bike, hike and have recently gotten back to running. I'm running a 5K on Thanksgiving Day. I feel 20 years younger. Life is good.
My advice to anybody starting this journey, is...do your research on-line. Ask a lot of questions, talk to resurfacing docs, not just docs that do THR's. Resurfacing is an amazing surgery...I never think about my hips anymore. The only thing Dr. Gross told me I couldn't do was Bungee Jump - No Problem!!!
Good luck to everyone trying to find the best option for them. If anybody has any questions for me, I'll be happy to answer them.
All the Best,
Linda
 

cdnlager24

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Hey Mike....can you tell me the lottery numbers? Cause making the statement about BO Jackson, having a BHR vs a THR, well you must be able to predict the future.

This is what I hate about these types of sites, people stating things they know NOTHING ABOUT.

People, please keep your comments to FACT, what has happened to you, or factual research.

Daniel

PS

Mike, send me those lotto numbers
 

Laurie

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THanks Daniel. Have to say that Mike's comments were not only hard to decipher but puzzling. From one who had a TH replacement on August 26 and is doing more than ever activity wise (yes, I can cross my legs, work out at gym, have no hip precautions -- didn't after 1st month) his observations about others with THr's seems off base. Am sure others would say the same on this site.

No matter, as has been said before, it is wonderful that we have options and that most of us are doing very well indeed whether replacement or resurfacing. Very personal choice to say the least.

And good luck with your surgery. My brother in law had resurfacing (birmingham) done by military Dr in DC area last year and is doing real well.

Laurie
 

Josephine

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Daniel, you have made a good point. I have just been talking to the reative of a friend who had THRs and is having problems. When he said where he'd had his surgeries, I had to tell him that those were mediocre hospitals. He replied that they had come 'highy recommended'. By whom? By people he knew and had met at various clubs and places, people who had had their THRs done there and were extremely satisfied. Well, let me tell you that is no real recommendation at all!

Over the years I have seen a variety of questionable
procedures (and I do NOT include HR in that) devised by surgeons. Of the several dozen or even hundreds of patients on the receiving end of these procedures, there were many, many that were very happy with the results. But the percentages of people on the other end of the scale were too many to make the procedure an acceptable means of treatment for what ever condition. There were too many patients worse off that they had been before. Obviously that is unacceptable.

Now as far as HR is concerned, I have read numerous papers on them over the years. I have been included in discussions on hip surgery by surgeons of high repute (meaning high repute by their peers not the general public) and always the figures and opinions have been the same. HR is fine - an excellent procedure in certain circumstances and in the hands of those who have studied it and practiced it to the nth degree. You could say that about an awful lot of procedures.

But nowhere and no time should a procedure and/or surgeon be judged purely on the basis of the satisfied customers who happen to cross your path and extol their virtues. It means nothing. You could engage a builder that a neighbour used and was happy with. But you still don't really know about the quality of his work - only another builder would be able to judge that for you. He might also tell you himself that he has this many years experience and has done work for Lord so-and-so. Self promotion is also a no-no.

See what I mean? It all comes down to this; on what basis is the other person telling you that Mr X is a superb surgeon? Because he and a colleague have been happy with the outcome of their surgery and like his bedside manner? Would NOT be good enough for me.
 

Rainer

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I had RA done more than 4 years ago and I have not regretted a single moment.

As a matter of fact, I am forever grateful that I found out about RA before I went ahead with a THR.

A THR was recommended by one of the top hip surgeons in Toronto when I first went to see him back in 2000. Never once did he mention the option of RA. Because I was, and intended to continue to be, very active, I was relentless in pursuing other options.

Eventually I came across RA. I researched and "interviewed" hip surgeons for almost 5 years until I found the right one for me -- right in my own back yard.

I am active in one of the most physical of sports - judo. I have friends with RA hips who are active in competitive judo at the international level. There is very little likelihood that they would be this active with a THR.

I recommend to everyone that they DO THEIR RESEARCH before making a decision.

Here is the BEST piece of advice I can offer to anyone considering hip surgery: Go to a surgeon who does both procedures - THR and RA. If you're not a candidate for RA, he will give you an UNBIASED opinion.

The most important factor will be bone density. I have a teacher who was in his 70s when he had his RA done. He had the bone density of a 20-year old.

In the end, it may not matter to you which procedure you have done but for those who do care, remember it's your body and once it's done, it's done.

You have to be your own advocate these days.

Let me give you one final example of this:

I have had several joint surgeries due to sports injuries. Recently I had one final one done to repair a torn rotator cuff in my shoulder. Compared my other surgeries, it seemed to be a no-brainer and I didn't do my normal upfront research.

Six weeks after my surgery, I discovered my surgeon had done a little 'extra' while he was in there - he severed one of the tendons of my biceps! Not by mistake, but because he felt it was a good idea.

Never mind the fact that I now have a 'popeye' effect on my biceps and 20% less strength in my biceps.

In the end, I may have ended up doing the procedure anyways but it would've been nice to know about the possibility of a severed biceps BEFORE the surgery.

Too many people blindly follow one doctor's advice. If it doesn't sound right to you, do your homework. Do your research. Talk to others who have had it done. Spend some time on your own health. Read, listen and make your own decision.

Rainer
 

vxm

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" Shimmin et al (5) found no difference in gait analysis between RA and THA patients. "

Here's a study that shows the contrary:

http://gait.aidi.udel.edu/gaitlab/gcma/info/abstracts/O13.abs20141.pdf

Gait Analysis Of Metal On Metal Surface Arthroplasty

Adult Reconstruction Hip
Phillip Ragland, MD Washington DC (n)
Anil Bhave, MS Baltimore MD (n)
Roland Starr, MS Baltimore MD (n)
Michael A Mont, MD Baltimore MD (a, e - Wright Medical Technology)


This study compared gait kinematics of resurfacing patients to normal hips, osteoarthritic hips, and patients with standard hip replacements. Metal-on-metal resurfacing is a type of hip arthroplasty in which there is conservation of the proximal femur. Little is known about the functional capabilities of patients with resurfacing. This study compared gait parameters of resurfacing patients with normal and osteoarthritic hip patients as well as those with standard hip replacements.

Utilizing a gait analysis laboratory, the authors compared temporal-spatial parameters and hip kinematics during walking in patients with unilateral osteoarthritic hips, unilateral standard total hip replacements, and unilateral total hip resurfacing arthroplasty (Forty-one total patients; 15 standard total hip replacements, 15 resurfacing, and 11 unilateral hip osteoarthritis). Inclusion criteria for surgical patients included Harris Hip Scores > 90 points and be minimum twelve months post-operative. All patients had gait analysis and the data compared to a matched for age and gender normal hip population. The gait parameters assessed included abduction moment, extensor moment, and walking speed.

Superior hip kinematics were found when resurfacing was compared to standard hip arthroplasty as well as osteoarthritic patients. Resurfacing patients had kinematics (abduction moments, extension moments, walking velocity) that approached the normal patients without hip osteoarthritis. Deficits of patients with resurfacing were small.

Resurfacing patients had gait characteristics that were comparable to normal hips. Although standard hip replacements had markedly improved gait parameters when compared to osteoarthritic hips they never approached resurfacing or normals. The reasons for these findings are unexplained but may be due to the large femoral head which deserves further investigation.
 

susette

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Hi, I thought I might chime in here about my hip experience. I sure agree that research and lots of it is the key to a successful outcome! I was diagnosed about 6 years ago with *Protrusio Acetabuli* . Another name for my version of this disorder is *Otto Pelvis*. Of course I'd never heard of it at the time so I hit the internet and did a med-line search at the library. This disorder is characterized by very deep hip sockets into which the femur migrates until it makes medial/posterior contact with the pelvis. I certainly was surprised when that Orthopedic surgeon told me I needed bilateral THR's.

As everyone here knows, that is tough news and I was having a hard time accepting it. I searched relentlessly for someone with Protrusio Acetabuli. I don't know how I missed this web site! I finally came across someone on a web site similar to this who had a friend who had Protrusio Acetabuli and she referred me to her. Well, that girl had her protrusio hip RESURFACED by Mr. Treacy in Birmingham, England so that got me researching Birmingham Hip Resurfacing.

To make a VERY long story short, I researched like crazy. I knew that Dr. Koen DeSmet in Gent, Belgium was one of the most experienced resurfacing surgeons in the world ...he had done about 1200 at the time and that he had EXCELLENT outcomes and very low failure rates across the board...even with difficult cases like people with dysplasia and AVN and older women and smaller women.

I knew I was a difficult case so I wanted the best. I was 52 at the time. I made a digital copy of my hip x-rays and e-mailed them to Dr. DeSmet and he immediately got back with me FREE OF CHARGE and told me I was a good candidate! Consequently I travelled to Belgium and had my worse left hip resurfaced.

It was an amazing experience. He grafted the bone material that he reamed from the head of my femur into my deep acetabulum to build it out before he press fit the porous cup into which that bone magically grew. He literally re-positioned my acetabulum. Then he perfectly placed that little cap over the head of my femur. I was up walking the next day with elbow crutches and left the hospital on day 3 for another week of rehab. I was down to one crutch on day 10 and free of any aides by 4 weeks. My range of motion is amazing.

It's been 3 and a half years now! Do your research! Check out those doctors and get multiple opinions! If you think resurfacing might be good for you and your doctor (like my doctor who originally diagnosed my protrusio) doesn't do resurfacing and talks negative about it then get an opinion from someone who does both regularly. Some doctors just don't know enough about the new developments in hip resurfacing so they are reluctant to recommend it.

I know doctors because I am married to one! Some just don't like to admit that they don't know everything but don't tell my husband I said that! Susie
 

susette

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YES VXM, you are correct! I have a copy of this article. This study shows that the gait of a person with a resurfaced hip is more like that of a biologic, normal hip. ..Susie
 
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