HR Issues

Do you have questions about pain medications.

 

What are NSAIDS, narcotics, acetaminophen combinations? Emedicine Health.com has a great article about everything you would want to know about these medicines. What they are, how they work, possible addiction and withdrawl.

 

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Age Chart of Hip Resurfacing Patients

 

List and chart of hip resurfacing patient's ages. This chart is a representation of the hip resurfacing patients that use the Yahoo Surface Hippy Discussion Board.

 

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Acetabular Bone Loss by Dr. Vijay C. Bose

 

...The acetabular size is the most important factor which determines the choice of femoral head size in resurfacing and one never removes more acetabular bone in hip resurfacings. In other words if I would be performing a conventional hip replacement on a given patient instead of resurfacing, I would be using precisely the same size acetabular component in both the surgeries.

 

I would go as far as saying that if we are taking out more acetabular bone in resurfacing than in conventional hip replacement , then in my opinion there is no role for resurfacing and it must be discontinued immediately. Acetabular conservation is as important if not more than femoral bone conservation and all resurfacing surgeons recognize and acknowledge this fact. The ability to put large heads in resurfacing stems from the fact that thin shelled acetabular components are possible with the modern metal on metal bearings. However when one uses polyethylene it has to have a large thickness ,which in turn reduces the femoral head diameter , (assuming the acetabular outer shell diameter remains the same). The same argument holds true for ceramic on ceramic bearing to a lesser extent and therefore slightly large femoral head sizes than metal on poly is possible. However an anatomical size is currently possible only with metal on metal bearings...

 

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The First Hundred Surgeries How Surgeons Acquire Experience by Dr. Rubinstein Sent: Sunday, June 10, 2007 2:53 AM Subject: THE FIRST HUNDRED Hi All, Just catching up after not having time since the end of may. I noted many posts on the number of cases (a new surgeon) needed to become proficient. Some mentioned it being bogus to learn on patients and other similar comments. I ask everyone to consider that everyone needs to start somewhere and all surgeons (even Gross, DeSmet and McMinn) had to do their first resurf and their next 99 prior to reaching 100. This issue is one that is difficult for me because I set very high standards for myself and always want to do the best thing for my patients. That is why I became interested in the resurf concept. As I went through my first 50 cases I was always questioning my experience and analyzing the results to be sure I was doing the best surgery I could. On the one hand you know you don't have the experience that some others do. On the other hand there is no way to get it without doing the cases. It is a very difficult issue for a surgeon. I resolved it by training as follows: 1)observing surgery with three differant resurf surgeons. (Gross, McMinn and Stachniw)prior to doing my first case. 2)Taking the formal BHR training course. 3)Carefully selecting my early cases to be straight forward. 4)Carefully reviewing each case looking for ways to improve. While I realize the importance of experience as I hope most of my fellow surgeons do we all must start somewhere. There is really no way to resolve that issue. As for an individual deciding where to have the procedure done there is no easy answer. I would make sure first that you are comfortable with the surgeon and your experience on your visit. Ask questions and be comfortable with the answers. If you don't have a good feeling look elsewhere. If you personally set a minimum number of cases for your surgeon that's fine. But please don't insult the surgeons starting out by claiming them to be bogus. Most are like me when I started. Worried to death about doing a perfect performance every time while starting a new and difficult procedure. Doing their best each and every time and beating themselves up for every mistake no matter how minor. Ask my wife and she will tell you how much it bothers me every time something doesn't go perfect in surgery, even if it is something that won't affect the results. I take the responsibility and trust that patients give me very seriously and I feel the majority of the orthopods do. I hope that will give you all some insight into the moral dilema that faces a surgeon starting with a new procedure. If some of us don't learn and gain experience in resurfs then the procedure won't be widely available and many resurf candidates will lose their heads needlessly due to lack of qualified surgeons. Remember we all had to crawl before we learned to walk and then stumbled unsteadily before we learned to walk well. Thanks for reading this ramble. Scott Rubinstein M.D. Illinois Bone and Joint Institute, Chicago, Illinois www.hiportho.com

Conversion from Resurfacing to Total Hip Arthroplasty Posted April 26th, 2007 by Matt in Hip In recent years, resurfacing arthroplasty for the hip has become possible. Hip resurfacing arthroplasty is a type of hip replacement that replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement. The advantage of hip resurfacing is that by removing less bone it is possible to do a total hip replacement (THR) later. But surgeons are wondering if this type of revision is really possible? How often does it happen? There haven't been any studies on this conversion since 1980. And many things about the devices and the procedures have changed since then. In this study, surgeons at the Joint Replacement Institute in Los Angeles, California review a group of 20 adults who had the resurfacing procedure (the study group). All patients with resurfacing arthroplasty received the same metal-on-metal implant. The femoral head portion was cemented in place for all patients. The stem was only cemented in about 40 per cent of the cases. They compared the results with a similar group of patients who had a THR (the control group). Pain, walking, function, and activity were used as the measures of results. X-rays were also reviewed for both groups... ...The authors conclude that the proposed advantage of resurfacing arthroplasty (easy revisability) is real. Successful conversion to a THR is possible. They suggest a larger study needs to be done to confirm these findings. Longer follow-up time is also advised... Scott T. Ball, et al. Early Results of Conversion of a Failed Femoral Component in Hip Resurfacing Arthroplasty. In Journal of Bone and Joint Surgery. April 2007. Vol. 89-A. No. 4. Pp. 735-741. READ MORE

New Procedure Used To Save Bad HipsPOSTED: 2:53 pm PDT June 13, 2007 SAN DIEGO -- Doctors are using hip resurfacing as a new way to replace worn out hips. The procedure can spare the bone so younger patients with bad hips can remain physically active. Kevin McCarey is a seasoned athlete and has been waiting for this day. He is undergoing an alternative to hip replacement called Birmingham Hip Resurfacing. “This procedure is designed for younger people with arthritic hips. It’s a bone-saving procedure; it doesn’t remove the femoral head,” said Scripps orthopedic surgeon Dr. Michael Kimball. Kimball is one of the first doctors in San Diego to use the new method. "It's a bone preserving procedure. You don't remove any of the bone, you take off the cartilage and put this metal cap in place,” said Kimball... Six weeks after hip resurfacing surgery, McCarey said, “It’s just amazing how fast you come back. The pain is completely gone out of my hip.” McCarey is back to doing intense two to four-hour daily workouts and feeling stronger than ever... The procedure was recently approved by the Food and Drug Administration, but it has been used for more than a decade in England and Canada. READ MORE

Boomers Drive Demand The American Academy of Orthopaedic Surgeons projects that by 2030, 3.48 million total knee replacements and 572,000 total hip replacements will be performed annually in the United States. In 2004, the last year for which the academy has released data, U.S. hospitals performed 478,000 total knee replacements and 234,000 total hip replacements. The demand is driven by baby boomers who want to maintain active lifestyles. Advances in materials that make for longer-lasting implants mean more people are getting new joints at younger ages. Older implants had a life expectancy of 10 to 15 years; newer ones are expected to last years longer. In the 1970s, when doctors first started performing joint replacements, they generally wouldn't perform them on patients younger than 60, said Dr. Douglas Dennis, an orthopedic surgeon in Denver and spokesman for the national association. Nowadays, because materials are more advanced, patients in the 40s and 50s are getting new hips and knees. Widner adds a third reason the numbers are growing: the increasing prevalence of obesity, which puts more stress on joints. READ MORE

Antibiotics and Hip Surgery

Guidelines by the American Dental Association and Academy of Orthopaedic Surgeons

Advisory Statement

Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements

American Dental Association; American Academy of Orthopaedic Surgeons

An expert panel of dentists, orthopaedic surgeons and infectious disease specialists, convened by the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) performed a thorough review of all available data to determine the need for antibiotic prophylaxis to prevent hematogenous prosthetic joint infections in dental patients who have undergone total joint arthroplasties. The result is this report, which has been adopted by both organizations as an advisory statement. The panel's conclusion: Antibiotic prophylaxis is not indicated for dental patients with pins, plates and screws, nor is it routinely indicated for most dental patients with total joint replacements. However, it is advisable to consider premedication in a small number of patients (Table 1) who may be at potential increased risk of hematogenous total joint infection.

Approximately 450,000 total joint arthroplasties are performed annually in the United States. Deep infections of these total joint replacements usually result in failure of the initial operation and the need for extensive revision. Due to the use of perioperative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intraoperative contamination has been markedly reduced in the past 20 years.
Patients who are about to have a total joint arthroplasty should be in good dental health prior to surgery and should be encouraged to seek professional dental care if necessary. Patients who already have had a total joint arthroplasty should perform effective daily oral hygiene procedures to remove plaque (e.g. manual or powered toothbrushes, interdental cleaners, oral irrigators) to establish and maintain good oral health. The risk of bacteremia is far more substantial in a mouth with ongoing inflammation than in one that is healthy and employing these home-oral hygiene devices.1

Bacteremias can cause hematogenous seeding of total joint implants, both in the early postoperative period and for many years following implantation.2 It appears that the most critical period is up to two years after joint placement.3 In addition, bacteremias may occur in the course of normal daily life4-6 and concurrently with dental and medical procedures.6 It is likely that many more oral bacteremias are spontaneously induced by daily events than are dental treatment-induced.6 Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent hematogenous infections is required prior to dental treatment in patients with total joint prostheses.1 The risk/benefit7,8 and cost/effectiveness7,9 ratios fail to justify the administration of routine antibiotic prophylaxis. The analogy of late prosthetic joint infections with infective endocarditis is invalid as the anatomy, blood supply, microorganisms and mechanisms of infection are all different.10

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The modern BHR version of hip resurfacing is quite different than the earlier surgery performed in the US. The older hip resurfacing surgery, called a hemi-resurfacing, only placed a metal cap on the head of the femur bone. The metal cap then protected the femur bone, but rubbed the bone inside the acetabulum of the hip. The metal cap caused wear and tear against the bone in the actabulum and often required early revisions of the original surgery to a Total Hip Replacement (THR).

The new BHR hip resurfacing surgery includes having a metal cap placed on the head of the femur bone, but also a metal cup placed into the acetabulum of the hip. The hip devices are called Metal on Metal (MOM) hips because both parts are metal. Therefore, the only friction caused by the hip device is metal against metal, there is no bone wear as in the older versions of hemi-resurfacing operations.

Mr. McMinn of the UK is the designer of the current BHR design and has been performing hip resurfacing surgeries for more than 15 years. Katie Ellis was one of Mr. McMinn's pioneering patients in 1991 and is still active with her original BHR.

One of my patients from India who has had a resurfacing, briefed me on the current discussion in the surfachippy forum regarding Dr. Klappers opinion of losing acetabular bone in an attempt to preserve femoral head bone in resurfacing. He wanted to know my opinion and I thought it would be appropriate for me to post my answer in this forum. Dr. Klapper's opinion is way off the mark. The acetabular size is the most important factor which determines the choice of femoral head size in resurfacing and one never removes more acetabular bone in hip resurfacings. In other words if I would be performing a conventional hip replacement on a given patient instead of resurfacing, I would be using precisely the same size acetabular component in both the surgeries. I would go as far as saying that if we are taking out more acetabular bone in resurfacing than in conventional hip replacement , then in my opinion there is no role for resurfacing and it must be discontinued immediately. Acetabular conservation is as important if not more than femoral bone conservation and all resurfacing surgeons recognize and acknowledge this fact. The ability to put large heads in resurfacing stems from the fact that thin shelled acetabular components are possible with the modern metal on metal bearings. However when one uses polyethylene it has to have a large thickness ,which in turn reduces the femoral head diameter , (assuming the acetabular outer shell diameter remains the same). The same argument holds true for ceramic on ceramic bearing to a lesser extent and therefore slightly large femoral head sizes than metal on poly is possible. However an anatomical size is currently possible only with metal on metal bearings. I strongly object to the terminology of "large or jumbo head metal on metal hip replacement" that some surgeons use to describe the current versions of the total hip replacements which employ the same metal on metal bearing used in resurfacings. I point out in all my lectures that this variety of total hip replacement is the anatomical head replacement giving the same natural size ( of the femoral head and the acetabulum) that the patient has in other normal hip and the conventional THR are indeed small head hip replacements. One must never lose this perspective. I hope this helps to clear the sudden doubt that was cast on the hip resurfacing principle recently. Dr. Vijay C. Bose Consultant orthopedic surgeon Chennai, India