Doctors

Hip Resurfacing Learning Curve for Surgeons

 

ORTHO Supersite News Wire (June 20, 2007)contained a link to an article from Orthopedics International 2007, 10:10, May 2007, which describes a study from Diane Back on the learning curve for correct placement of the femoral hip resurfacing components. Instead of the 10 to 20 cases expected it actually took from 50 to 60 cases for the surgeons studied to place the components where they wanted it (+/-5% of target). In the United States where orthopaedists begin practicing after completing fewer hip replacements than surgeons in the United Kingdom or Australia, "It actually means their learning curve may take them 10 years to get out of," Back said. She also recommends that surgeons just learning the procedure should tell patients they are at the beginning of their learning curve and have not done many of the procedures.

 

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Information in the News Wire:

 

* Diane L. Back, FRCS, Ed Orth, can be reached at Guy's and St. Thomas Hospital National Health Service, Lambeth Palace Rd., London, SE17EH, England; +44-20-7188-4435 ; e-mail: diane.back@gstt.nhs.uk. She has no financial disclosures related to this presentation. * Back DL, Smith JD, Dalziel RE, et al. Establishing a learning curve for hip resurfacing. #130. Presented at the American Academy of Orthopaedic Surgeons 74th Annual Meeting. Feb. 14-18, 2007. San Diego.

How To Select a Surgeon for Hip Resurfacing by Patricia Walter

 

Selection of a surgeon is a personal choice. It is a choice that makes you feel confident that your surgery will go well, that your surgeon has a good bedside manner and you can ask questions anytime you need answers.

 

When buying real estate the old saying about what is important is "Location, Location and Location." In many people's minds the most important factor in choosing a surgeon for hip resurfacing is "Experience, Experience and Experience." I realize that every hip resurfacing surgeon has to start somewhere to do his first operation, but I feel, in layman's terms, that hip resurfacing is as much of an art as it is a learned skill. The angle of the cap on the femur bone is very important, the proper amount of pounding to place the stem is important, shaping the femur bone for the cap is important, how the surgeon approaches the hip itself is important.  There are many, many factors involved in a successful hip resurfacing operation.

 

There have been studies done to determine the learning curve for Hip Resurfacing with the BHR and for Hip Resurfacing with the ASR. These studies and others indicate that a surgeon needs 50, 100 or more hip resurfacing operations to become experienced. I have personally been told by a very experienced doctor that a surgeon should do at least 100 hip resurfacings before a patient decides to use them. There is a LARGE AMOUNT of debate over this number and subject.  Many people feel that a surgeon is already experienced if he has been performing THR's for many years. Hip Resurfacing, however, is a much more demanding and technical surgery than a THR.

 

 

I personally feel that experience can only be learned, it can not be taught. Many professional sportsmen have learned the technical skills to play the game - but you generally see the most experienced quarterbacks, pitchers, or goalies playing in the pros.  The difference is the experience. These people learn almost instinctively what to do, they don't take time to reason and figure out what to do.  That is the kind of surgeon I want to do my hip resurfacing - a surgeon that has seen it all and done it all.  Unfortunately a surgeon that has only done 10 or 50 hip resurfacings has not seen it all and done it all.  My personal surgeon, Dr. De Smet, even told me that he still has very difficult surgeries and he has done over 2500 hip resurfacings.

 

I feel if a person has a more difficult hip problem such as advanced AVN, cysts, misaligned hips or an unusual physical problem they were born with - they need a very experienced surgeon. If you are an older female or even male, many surgeons will suggest a THR instead of a BHR.  The more experienced doctors are more willing to tackle more difficult problems since they have the experience.

 

I have personally read thousands of emails from hip resurfacing patients on the Yahoo Surface Hippy Discussion Group. My personal observation of post-op results show that the patients of the much more experienced surgeons usually have a quicker and easier recovery. There are always exceptions often due to the prior medical condition of a patients hip or muscles, but anyone can take time and read thru the thousands of emails on the discussion group and see how patients recover after their surgeries.

 

To sum up the question of "How to Select a Surgeon", choose a doctor that you feel comfortable with. Ask the doctor:

Some of the newer doctors are not as comfortable with hip resurfacing and will revert back to a THR if they encounter problems.  A THR is an easier operation than a Hip Resurfacing.  Make sure your doctor is a true advocate of hip resurfacing. Some of the new doctors have told me that they only use hip resurfacing in special situations and still prefer doing a THR in most cases. The very experienced hip resurfacing doctors will always give a person a hip resurfacing if possible - some have even changed their mind during a THR and ended up giving a patient a hip resurfacing.

 

Ask questions and opinions from other people, then trust your own instincts and make up your own mind. It is your hip and your life.

 

Patricia Walter Webmaster/Owner of Surface Hippy - A Patient to Patient Guide to Hip Resurfacing

 

South County doctor local pioneer in hip resurfacing 05:16 PM EDT on Friday, June 22, 2007 By Felice J. Freyer Journal Medical Writer

 

SOUTH KINGSTOWN

 

The guys wanted it. Guys in their 40s and 50s, who once spent hours playing tennis or doing karate, and who, now hobbled by arthritis, poured their energy into finding a solution to the pain in their hips.

 

They came to Dr. Robert C. Marchand, printouts in hand, minds made up, and said, I want this. What they wanted was hip resurfacing — a new alternative to total hip replacement that preserves more bone, and is reputed to last longer, withstand impact and allow a greater range of motion. Perhaps allowing for more years of karate kicks.

 

Marchand, who is with South County Orthopedics, had observed a hip resurfacing procedure in his wife’s native Germany. In Europe, he says, people are running marathons with hip-resurfacing implants. He thought his patients were on to something, and resolved to give them what they wanted.

 

He took a course last year in hip resurfacing in Boston and went to New York to train with a surgeon there. After persuading South County Hospital to buy the necessary equipment, he began doing the procedure last fall. So far, he has completed about 45 resurfacing procedures in people age 20 to 71. And he remains the only doctor in Rhode Island who will do it...

 

In the traditional treatment for arthritic hips, called total hip replacement, the surgeon saws off the top of the thigh bone, hollows it out and inserts a metal implant topped by a metal or ceramic ball, which rests inside a plastic cup implanted in the hip socket.

 

In hip resurfacing, instead of sawing off the top of the thigh bone, surgeons reshape it, preserving most of the natural ball. Then they cement a metal cap over the ball, which slides inside a metal cup pressed into the hip socket. Both are made of cobalt chrome.

 

Some think this metal-on-metal construction will last longer and withstand high-impact activities such as running. More bone is preserved, so that even if the implant does break down, the patient can then get a total hip replacement. Also, the ball is bigger, thought to be less likely to dislocate from the hip socket, and affording a greater range of motion.

 

All this makes the procedures especially popular with active baby-boomers. “They come in at six weeks [after surgery], cross their legs and put on their shoes,” Marchand says. “They say, ‘I haven’t done this in a year.’ ”

 

...EVEN AS patients exult, the debate continues among doctors. Dr. Scott Rubinstein, a Chicago orthopedist who favors hip resurfacing for appropriate patients, says many are discouraged from it by surgeons who don’t do the procedure.

 

“If someone’s interested in getting this done, they need to be evaluated by someone who does them,” Rubinstein said. “It’s certainly not appropriate for everyone. You need to look at this as one way to have your hip done. Like any surgery, there’s no right answer for everyone.”

 

In looking at the evidence, it may come down to a question of whether one sees the glass as half-empty or half-full. Rubinstein, like Marchand, finds the 10 years of data from Europe convincing. “I don’t think it’s going to be any worse than the other stuff. I personally think it’s going to be better,” he says. “It’s one of these time-will-tell kind of things.”

 

...Dr. John A. Froehlich, of University Orthopedics, who specializes in sports medicine and reconstructive surgery and practices at Rhode Island Hospital, also says he’s not ready for that bandwagon.

 

But he points out that patients are not facing a simple choice between old-fashioned total hip replacement and brand-new hip resurfacing. The traditional hip replacement technology has also been advancing, with procedures that preserve more bone, more durable materials, and smaller incisions.

 

He’s pleased with the results he’s getting with the latest versions of hip replacement. “I think I can give people a more predictable result the way I’m doing it,” Froehlich said.

 

With people now living into their 80s, and getting sore hips in their 50s, anyone who gets hip surgery is going to have to have it redone, perhaps multiple times, Froehlich adds. “No matter what they’re made of, they will loosen and wear. That is something that is not recognized by the public,” he says.

 

“There is no panacea.”

 

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Outsourcing to India hip surgery

 

05:21 PM EDT on Friday, June 22, 2007

 

By Felice J. Freyer Journal Medical Writer

 

When Anne Grant needed surgery on a painful arthritic hip, she didn’t go to a hospital in Rhode Island. She didn’t even go to Boston.

 

Instead, she packed her bags for India.

 

Yes, India — where Indian doctors and nurses performed the procedure that Grant wanted for a fraction of the cost in the United States. Five months later, the 61-year-old Providence woman says she’s walking and swimming without pain.

 

As surprising as her choice may seem, in heading to India, Grant joined tens of thousands of other Americans who are going overseas for medical care — to India, Thailand, Brazil, Singapore, to name a few places...

 

...“Our research showed us a very large group of aging baby-boomers were beginning to age into expensive treatment without being able to pay for it,” said Josef Woodman, author of a new book on the trend called “medical tourism.” Many are too young for Medicare but don’t have insurance — and they’re looking for help overseas.

 

Woodman estimated that last year, 150,000 Americans went abroad for medical treatments. Based on interviews with travel agents and reports from international hospitals, Woodman made the educated guess that half sought dental care in Mexico and cosmetic surgery in Brazil or the Caribbean, and the other 75,000 went for major, necessary procedures at international hospitals in Asia.

 

...Then, at a dinner party last year, her friend Lisa Grant — a neighbor, but no relation — mentioned that she, too, had a bum hip, and she was going to Belgium to have it fixed. From a 60 Minutes episode, Lisa Grant had learned about hip resurfacing, a new approach to hip replacement that preserves more of the thigh bone and is reputed to last longer. (See related story.) Although performed in Europe for more than 10 years, hip resurfacing is new in the United States, having received FDA approval only in May 2006.

 

Lisa told Anne about surfacehippy@yahoogroups.com, an Internet listserv rich with patients’ reports of their hip-resurfacing experiences. ..

 

Asked about Americans seeking cheaper care overseas, Lonks said, “You get what you pay for.”

 

He raised numerous concerns. “What happens if you have the procedure, come back to United States and you develop a complication? Who’s going to take care of it? Will your insurance cover it? … How do you know about the sterility and quality of their equipment? How about if you need a blood transfusion in India? … How about malaria? … How about typhoid or measles? Measles is a common disease in India.”

 

In an e-mail responding to The Journal’s questions about the risk of infections, Grant’s surgeon, Vijay Bose, said that “the patients are in a protected environment” and called the chances of catching something like malaria “very remote.”

 

“Over the last three years where I have been doing a large volume for American patients, we have not had a single case of malaria or other infectious diseases,” Bose wrote. He also said the hospital’s blood bank is comparable to any in Europe or North America, so patients who need a blood transfusion face the same low risks as anywhere. (Grant did not need any blood.)

 

As for the low cost, Bose had this comment: “I personally do not think that the cost is cheap in India. It is just the actual and appropriate cost for various procedures. The converse is true, it is artificially boosted and very high in the U.S...

 

...LARGE BUSINESSES and health insurers looking for lower-cost health care are watching the medical tourism trend with interest. But, says Mohit M. Ghose, spokesman for America’s Health Insurance Plans, the national trade group for health insurers: “What you have not seen is a rush by our sector to jump on board.”

 

He said insurers are worried about “legal and quality issues,” particularly who is responsible for patients’ care upon their return. Patients often cannot collect compensation if they are injured. So who will pay for the care at home if there are complications?

 

Ghose thinks the global competition will further boost a trend already under way in the United States — to develop “centers of excellence” that do many procedures, provide consumers information on how well they perform and compete on the basis of quality.

 

Ghose says he knows of only one health insurer that has gone as far as offering an overseas option to subscribers: BlueCross BlueShield of South Carolina.

 

In February, David Boucher, South Carolina BlueCross’ assistant vice president of health care, founded Companion Global Healthcare, a medical tourism agency that has a relationship with the Bumrungrad International Hospital in Bangkok. To address concerns about follow-up care, Companion contracted with a large network of South Carolina doctors to take care of patients when they return from overseas treatment.

 

“We’re not contemplating mandating care abroad,” Boucher stresses. “This is an option — we just want to help them make it a little bit easier.”

 

So far, South Carolina BlueCross’ offer to pay for medical care overseas has attracted lots of media attention and inquiries from other insurance companies — but no patients.

 

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