THR Should I Cancel My Left Hip Replacement?

[ljpviper]

I think Dr. Prichett is one of the only hip resurfacing doctors that does not use metal on metal. He is a great surgeon. I beleive he also does hip replacements as well.

Most hip replacement surgeons frown on resurfacing. I tend to agree to avoid metal on metal.

Good luck.

 

[CatchAll]

My communications with the surgeon's office are starting to make me laugh...

Me: I would like to find out if there is any reason why I might choose resurfacing over the replacement surgery I have scheduled in less than two weeks.
Them: We need all of your medical records and xrays before we can determine if you are a candidate and schedule a surgery.
Me: I just have some questions about the procedure. By the time I request my records, mail them to you, and schedule an appointment my hip will be replaced.
Them: We can't tell you anything until we have reviewed your medical records. I will have surgery coordinator contact you.
Surgery Coordinator: We need all of your medical records and xrays.
Me: I just need to know if there are any reasons why anyone would choose resurfacing over replacement.
Surgery Coordinator: We at least need your most recent xray and fill out the new patient forms.
Me: Here's a picture of my xray and the new patient forms. I just need to know what factors someone would consider when choosing resurfacing instead of replacement.
Surgery Coordinator: I spoke with the surgeon. You are a candidate for resurfacing. We will need to do an evaluation before we schedule a surgery. Do you want telehealth or in-office?
Me: Get me a telehealth visit asap. I need to decide if I'm going to cancel my left hip replacement or there will be nothing left on which to operate. Again ... I just need to know if there are any reasons why someone would choose resurfacing if one hip is already totally replaced.

In my mind: Geez. It's like I'm asking for the Coca Cola recipe. While you are at it can you tell me where they buried jimmy hoffa, who was the second shooter on the grassy knoll, and what blend of herbs and spices colonel sanders puts on his chicken?

 

[CatchAll]

Continued...
Surgery Coordinator: We have a telehealth opening on 12/23 to discuss your surgery options.
Me: By 12/23 there will be a ceramic ball where my femoral head used to be.

 

[Schaargi]

In my mind: Geez. It's like I'm asking for the Coca Cola recipe. While you are at it can you tell me where they buried jimmy hoffa, who was the second shooter on the grassy knoll, and what blend of herbs and spices colonel sanders puts on his chicken?

I giggled at your last paragraph, although the concept is not funny. So frustrating, especially when you have a deadline.

 

[Going4fun]

At that time the surgeon said he had been doing resurfacing for almost 30 years and had not had a failure yet. I have some buyer's remorse now.

The above information is impossible. Every surgeon has failures. Impossible to not have failures. Derek McMinn, the creator of the Birmingham Hip Resurfacing device, has had extraordinary success, one of the highest success rates in the world for resurfacing. And he's had failures, and a higher number among women. The BHR is now basically not allowed on women. But even on men there are failures.

Dr. Edwin Su, who trained under McMinn, literally attracts patients from around the world for resurfacing at Hospital for Special Surgery in New York. Dr. Su is absolutely top notch, and patients basically pay out of pocket because insurance doesn't much cover his services. Anyway, Dr. Su has failures and reports them in regular studies.

Any surgeon who reports no failures in nearly 30 years is apparently cutting toenails.

 

[CatchAll]

@Going4fun Keep in mind I was asking an individual to recall a conversation that he had with the surgeon over 5 years ago. I expect that there were some qualifications to that statement that the patient is not now remembering, or his memory is completely wrong. Maybe it was no failures due to causes X, Y, or Z. From a quick review of some of Prichett's published works, I see that in one letter to the editor of the journal of arthroplasty he said that he performed 2000 resurfacings with highly cross-linked polyethylene with follow-up as long as 14 years and that there were no bearing surface failures. It might be that the patient is only remembering the failure rate of that component and not that there is a risk of femoral neck fractures, acetabular cup loosening, etc. In the data to his other published works revisions numbers are stated. It does appear however that the revision rate on his resurfacing procedures might be lower than total hip replacements. From reading some of his papers it seems that he has an interest in the longevity of implants in younger active patients.

 

[Going4fun]

I was just making the point that you don't need to have buyer's remorse, to use your words, in thinking that there was some surgery or surgeon out there that performs a hip replacement/resurfacing surgery without complications and revisions. That doesn't exist in a surgery as complicated as hip replacement.

Dr. Pritchett has a study I remembered (and just rechecked) reporting on resurfacing survivorship 8 years out. And he reports a survivorship of 97 percent at 8 years out. That's in line with the results of top total hip replacement surgeons.

There are advantages of resurfacing (as well as risks) compared to total hip replacement, but one of those advantages is not avoiding revisions and complications. Resurfacing does tend to attract a highly athletic and healthy group of folks as it requires work to even find out about resurfacing.

 

[CatchAll]

@Going4fun The source of my buyer's remorse is that I went forward with total replacement based on incomplete information due to my surgeon's negative comments about resurfacing. With what I know now, I would have at least scheduled an appointment with Dr. Pritchett before having total replacement of my right hip and it is likely that I would have had him resurface it. At my age it is almost certain that both hips will need a revision regardless of whether they are resurfaced or replaced. The difference is how soon the revision will happen, how complicated the revisions will be, and what I can do in the mean time. Between now and my first revision I would have liked to participate in higher impact activities. I have talked to a couple of resurfacing patients now and they are not giving any thought to the activities in which they choose to participate. I keep looking at activities and wondering if I will dislocate my hip or break my femoral stem loose or wreck this thing in some other way. I was walking past an ice rink with my son a couple of weeks ago and wanted to teach him to skate, but I was too scared.

 

[Schaargi]

@CatchAll

I know I'm older than you (I'm 57) but I really am feeling your pain. You love CrossFit and jumping and running! That's what you did before all of this. It was your thing. You want to be able to live life without fear. That's a big deal.

I understand the buyer's remorse, too. I am second guessing my first hip and wish I had asked more questions. My range of motion stinks, which limits many of my favorite activities. I feel like I should have questioned more and researched other options, like a dual mobility implant. At the time, I didn't realize there were so many options.

The constant fear that I might fall or somehow damage it was something that completely surprised me. I hope that I can gain some confidence in the next year or so, because living with this constant fear is not ok.

I kinda expected it to be more back to normal because so many people say that they can do anything they want. I guess I want to do different activities than other people.

And OMG, if people keep telling me to take up cycling, I'm going to barf. I'm seriously bad at biking, and the indoor one feels like a hamster wheel. It's decidedly not my thing.

I expect my second replacement to be a bit more forgiving, so I will be lopsided. I wish I had done more research, and I admire yours.

Please keep us updated. I appreciate your posts.

 

[Hippiex2]

I was told that I wasn't a candidate for resurfacing. If the arthritis is classified as mild then it would be a a possible option. If moderate to severe OA with very little to no cartilage then definitely no. I have had both hips replaced by anterior approach and made sure they were both this year as well due to the out of pocket max. I'm not sure if this info helps but figured I would at least share just in case it could help with the decision. My situation may be different due to congenital hip dysplasia as well. This is probably why they want medical info and X-rays first before even discussing the possibility.

 

[Autumn01]

Catchall you have answered yourself. Resurfacing is what you dream of, want and lust over.

so dont let money…a couple of grand stand in your way. Money will be forgotten. loss of memories…frustration….regrets…wont be.

i bumped myself up..paid extra…to go the robotic route. i am so very glad now that I did!

as to range of movement….well either way new prosthesis are better. some restrictions are kept because some people tend to be stupid And do stupid things. Doctors tend to want to protect them so leave in old ruled in accumulated layers. i did consider the double but at my age I am becoming more sedate by choice.

what I didnt compromise on was giving my surgeon the best tools to help me with. Reading that cup placement is a 50:50….pin tail on donkey…published research stuff made me decide very quickly robotics was for me worth the extra cash To get that cup 100% To avoid wrong placement and dislocations, revisions and more surgery and more pain. In my case, with a left dysplesia wonky side, it was a brilliant option.

for you…..the extra money is worth it to get revision that you want, to allow you range of activity in spades for decades. Dont short change your life options, for a few grand.

And if for some reason it doesn't last, work etc… for as long as you thought….you have no regrets.

chose a good surgeon, the best possible , dont short change yourself on giving your surgeon best equipment options to work with. Live with no regrets. At the end of the day we take only memories with us.

we are extremely lucky to have all these options. Use them!

The results will be yours.

 

[CatchAll]

I had a very interesting conversation with Dr. Pritchett in Seattle yesterday. He is passionate about his work and the study of ways to improve the longevity of hip replacement and resurfacing procedures. His position is that anyone under 60 should consider resurfacing as an option (assuming that their bones qualify and they have access to a surgeon who has sufficient experience in the procedure). He truly believes it is a better surgery than total hip replacement for younger patients, not because of the ability to be more active, but because he expects the resurfaced hip to last longer. However, patients that choose resurfacing are taking on a higher risk of needing an early revision (approximately 3.5%). Some people are not comfortable taking that risk or shouldn't take that risk. He explained that there is a higher failure rate in the first 8 years when compared to total hip replacement, but the resurfaced hips that make it past those initial years tend to outlast total hip replacement when looking at 20 year failure rates.

One advantage of total hip replacement is that it gets rid of the femoral neck which apparently is a weak link in our bodies and prone to fractures, especially in older people. People of all ages can fracture their femoral necks, but nobody collects the data in the normal population under age 65 (medicare has data on older patients). This likely benefits the statistics for total hip replacement. After a certain patient age longevity of the implant is no longer a concern and the lower complication rates associated with total hip replacement make total hip replacement the clear choice in the over sixty something population.

 

[ljpviper]

He is really knowledgeable, i spoke to him about my resurfacing that went bad. Your correct the weaklink in resurfacing is the femoral neck. He thinks based on my symptoms and timeline i got necrosis and the cap collapsed.

Even a slight collapse will throw the mechanic of yor hip off. Its a complex surgery. As stated earlier i find the dual mobility feels more natural than the resurfacing component.

 

[CatchAll]

@ljpviper I wasn't able to get a telehealth appointment with my surgeon at a time that worked, so I asked my surgeon's PA about dual mobility implants. She said that they only use them for patients who have special complications. An example was a patient that had some fused vertebrate or a patient with an abnormality in the structure of their hip.

I'm going to cancel my surgery. I will need to make another appointment with my surgeon and have him go over his pros and cons of total replacement in light of what I have learned about resurfacing. I still might go with a total replacement, but I want my surgeon's rebuttal to Dr. Pritchett's comments. My main concern at this point is longevity. With insurance deductibles and out of pocket max, this additional due diligence will cost me about $8,000.

 

[Going4fun]

Sounds like you had a great conversation with Dr. Pritchett. Congrats!

Just a caution: surgeons don't really rebut the approaches of other surgeons. They typically focus on their own experience, their own thinking and their own philosophy of how to perform sucessful surgery.

Survivorship data is a bear because surgeons update the devices they use. The current generation of ceramic on highly cross-linked polyethylene is showing really low wear rates at around 15 years, according to two surgeons (including the one I chose) that I consulted. Beyond that, it's guesswork. My surgeon is hopeful that the device will last 30 years or so ... But he won't go any further than that. I think he let slip that he thinks I won't need a revision, but he's going beyond the current longetivity record.

I think it's extremely important to feel safe and "right" about your surgeon/surgery choice. Notice I said "feel." You want to feel right and good in addition to logically doing background. There's nothing worse than "compromising" on the surgery of this sort or going into a surgery not feeling right and then later running into problems. You end up second guessing yourself.

Hey, I don't know your insurance situation. But I did want to give you a warning. The phrase "out of pocket maximum" just isn't true in the way that a patient thinks. I've read many many stories of people getting hit with huge bills based misunderstanding this language (understandably so, the language is deliberately incomplete).

In the vast majority of cases, insurance companies do not include "out of network" services as part of their out of pocket maximum. So if the surgeon you choose is not in your insurance network, you run into major problems.

And then things get weirder. Insurance companies often say we cover 60 percent or 70 percent of out of network services. That's 60 percent of the maximum fee the insurance company has set. And sometimes (I want to say most times) companies set that maximum fee at a ridiculously low level--sometimes lower than the fee they pay to in network doctors. So the patient is responsible for all costs above the allowed billing rate that the insurance company has.

Out of pocket maximum means as long as you're using services billed at or below the level the company has set as maximum reimbursement. But no hip surgeon charges such low fees.

I was on a forum with a guy who went to an expensive surgeon (world famous) who didn't take insurance. He thought oh well, my plan will cover 80 percent of the out of network cost. So he calculated the numbers, thinking he would have to pay for the 20 percent ... and 20 perent of 20K was about four thousand dollars, which he was good with. And the plan had an out-of-pocket maximu, so he was feeling good. Wrong. His insurance company capped out of network billings at something like $4,000 ... so the guy was on the hook for the remaining $16K, which was far beyond the adversited maximum out of pocket expense.

Best solution: see if Dr. Pritchett is part of your insurance network. His staff should be able to figure that out. And hey, sometimes people are willing to pay more to get the surgeon they want.