Hip Resurfacing News

I am a 49 year old state highway heavy equipment operator. I have arthritis all through my body. Over the years my hip gave me some trouble but it would come and go until 2 1/2 years ago when it came and stayed. The pain got worse and worse until I was no longer able to hunt, fish, and on some days, I was unable to even do my job. The deciding factor was when my wife and I could no longer enjoy our 2008 Yamaha venture motorcycle. The pain was so bad I had to stop every 30 minutes and fall off (there was no graceful way for me to get off and on the cycle anymore and my rides were becoming few and far between.

Where we live no doctor will touch anyone for hip replacement younger than 60 years old, no matter how much pain you are in. I was lucky to know that my neighbor, also a young 47 had her hip resurfaced by Dr. Mont the previous year and she was doing great. We have great insurance that did not require referrals so my wife called on April 26, 2010 and I was shocked that I got an appointment on May 20, 2010.

I took my x-rays but they did new ones as soon as I got there. I figured I would see a phy. assit. and would have to come back to speak to the surgeon. NOPE. Dr. Mont came in and said I was perfect for surgery and that he had an opening on June 16, 2010. NO MRI. NO HIMHAWING AROUND. JUST EASY TO UNDERSTAND STRAIGHT TALK. So we took it.

I have never had any medical procedures of any kind done over the past 48 years, so all this was new to me. Dr. Mont assured me that he and his staff would make this as pleasant an experience as possible. The next few weeks before surgery went quickly.

I had pre-surgery testing. A physical (full exam) an ekg, a chest x-ray and lots of blood work. Except for some minor hbp all went well. Mt. Sinai does have a hotel/guest house on campus but it fills up quickly so if you are coming from out of town you need to call asap. We had to stay at a motel about a mile away.

We arrived early on the day of surgery (about 6:45am) and surgery was for10:15 am. The only thing we didn't like was that they take the patient in first. Put in the iv and get them in bed before a family member could come in. Being it was my first time I would have liked my wife there from the beginning. Then you get the 1000 questions. Ted stockings. You speak to the anesthesiologist and decide on general or spinal. I took spinal and I am glad I did. You won't remember anything.

When I woke up, Jill said I was a rough one and that they almost went to a thr, but Dr. Mont did get the resurfacing done. The normal incision size is 4-5 1/2 inches. Mine was 8 1/2 inches. No staples either. Dissolvable stitches. THE FIRST 30 HOURS ARE HELL. SO BE PREPARED. The pain pump does control pain but made me sick to my stomach, not nauseated. Just could not keep anything down and believe me, you will love the catheter for that first night. I also loved the compression machine on my legs. It was like getting a massage on your legs.

Day 2 catheter gone. Pain pump gone.. Pt got me up. SHOCKINGLY PAINFUL. Had to find something to control my pain so I could sleep. They did and I slept great all night.

What a difference day 3 made. Got me up and walked down the hall. I was ready to go home. We arrived home after a 3 hour ride and it has been awesome ever since, I am 1 week out and I am on a cane. I am driving (it was my left hip) . I take no percocet except 1 before bed.

I WANT EVERYONE TO KNOW HOW GREAT DR. MONT'S TEAM IS. JILL WAS AN ANGEL TO MY WIFE AND WE APPRECIATED HER SO MUCH. BUT EVERYONE WAS GREAT. THE NURSES IN SURGERY (ONE EVEN HELD MY HAND BEFORE SURGERY STARTED) IN RECOVERY AND ON THE FLOOR WERE AWESOME. A SPECIAL THANK YOU TO TERESA, KRISSI AND DAVID (THEY WERE MY NURSES ON THE 3RD FLOOR) WITHOUT THEM I WOULD NOT HAVE HAD THE GREAT EXPERIENCE I HAD. MY advice. DON'T WAIT AND STAY IN PAIN. GET YOUR LIFE BACK. CALL THE MIRACLE WORKERS AT DR. MONT'S OFFICE. I WOULD DO IT AGAIN IN A HEART BEAT. FROM THE BOTTOM OF MY HEART. THANK YOU.

WAYNE AND CINDY
 

In January of 2010, at age 38, I had the difficult decision of what to do about an ailing right hip that had been diagnosed as moving toward advanced osteoarthritis. I first experienced pain in the joint at the age of 26 when my regular doctor told that I should restrict my physical activity (i.e., stop running) and that I would likely need a hip replacement within 6-8 years. That just didn’t really seem like an option for me at that early age. I had been very athletic and active my whole life – starting with basketball, football and track through college and then playing competitive ultimate Frisbee since then, up to 3-4 days a week. Besides, I was still fairly mobile—the rest of my body worked fine—and I was still able to play all the sports I loved. So, despite my family doctor’s advice, I continued my regular activities for the next 12 years, just cutting back when I felt soreness or the stiffness became too painful. Over time, I realized I had to cut basketball out of my activities because it would leave me sore throughout the next day. Then running even a few miles would leave me sore as well. I noticed myself slowly having to cut back on activities I loved because of the pain and stiffness in the hip joint.

I visited a newer family doctor in late 2009 to inquire about what was possible. He told me I "have the hip of a 70 year old," and that I was probably a good candidate for hip replacement. He respected the fact that I was still very active, playing competitive ultimate Frisbee (now at the coed level) and wanted to see that I could continue that. He told me about new developments in hip replacement—namely, hip resurfacing—and referred me to an orthopedic surgeon who he said "wasn’t a surgery nut" and would give me a fairly objective opinion on my options. After I saw him and expressed an interest in hip resurfacing, he referred me to Dr. James Rector in Boulder, CO. I talked with Dr. Rector and he thought I’d be a very good candidate for hip resurfacing. So, after doing a couple weeks of research on the procedure (including quite a bit on the Surface Hippy site, which was a great resource), I decided to go ahead with it, and I scheduled an appointment for late January 2010.

My early post-op recovery was, by all measures, excellent. I was off of all pain meds within 5 days after surgery, I was walking with one crutch at about 9 days, I was walking without crutches by two weeks, and I was driving by 16 days after surgery! In weeks 2 & 3, I would sometimes use a crutch when going on longer walks, because I really wanted to work on maintaining a normal gait, since I didn’t want to normalize any kind of limp which I would still fall into doing sometimes without a crutch. The limp was not so much out of pain as because of the relative stiffness in the joint that was operated on.

I was very committed to making a strong and quick (as possible) recovery. For the first 3 weeks of PT (2 weeks at-home, 1 week outpatient), I worked on the standard exercises they typically give you for post-op strengthening and increasing range of motion. They were great, and I did them religiously every day. When I got to about 3 ½ weeks, I’d pretty much exhausted what they could offer in terms of PT and I got the go-ahead to get onto a stationary bike, and by 5 weeks I was even on the elliptical machine doing 15-20 minute workouts. By about 6 weeks, I decided to get a pool membership and begin working on some water aerobics, which were nice because they allowed me to work on my range of motion without much impact on the joint.

At about 2 months, I felt relatively mobile – I could go on long walks and I was in the gym doing light weights. I’d bike 2 miles to work every day, and I’d go to the pool when I could. It was about that time that I began doing plyometric exercises – the kind that runners and other athletes do to stretch and strengthen muscles—focusing on the ones that did not require any high impact. It was these exercises that made the biggest difference, I think, in speeding my recovery (I would be happy to share those that I did). I focused on ones that strengthened and helped stretch the hip-flexor and quad area muscles, as those seemed to remain the weakest muscles for me (particularly when lifting the knee and extending the leg forward). I continued to do these, along with weights and low impact cardio work, until about 12 weeks post op, when I added beginners’ yoga classes. I didn’t push myself to do everything in the class; just what I could without pain or without breaking the restrictions explained by my surgeon. Between these classes and the plyos, I was able to figure out what muscles seemed to be coming back strong and which remained weaker and needed more attention. Since I still had one fairly strong hip, I was able to use it as a barometer for what "normal" should feel like in terms of strength and flexibility. I made it to the gym 4-5 days a week, for about 1 – 1 ½ hours each time, working on plyos, stretching to increase range of motion, and weights (increasing to moderate by month 3).

When I saw my surgeon for a 3 month appointment, I was doing pretty well. My range of motion – bringing my knee toward my chest—still had a way to go and was limited and somewhat painful if I tried to stretch it too far. Otherwise, the joint strength felt good. He said things looked good, and told me I should keep up with the biking, weights, stretches, and that I could hike as long as I wanted. He told me I should not be doing any running until a full year after the surgery (beyond running to cross the street or something like that). I told him I was doing low impact plyos, and he seemed fine with that. Strangely, he also told me that he thought I could return to playing ultimate Frisbee by about 5-6 months post-op, which made me think: I don’t think he know what ultimate Frisbee is. For those who aren’t familiar, it’s a lot like soccer in terms of sprinting, cutting, jumping, changing direction, etc. So it didn’t make much sense to me, especially when he told me not to run for a year! I tried to explain to him what the sport was, but I’m not sure he ever got the idea of Frisbee golf out of his head – which is a whole different game! He said the fact that it was on a soft surface (grass) – rather than long-distance repetitive motion on something like concrete—made it less taxing on the new joint. He told me ever after the year of no running, I should refrain from playing much basketball. I’ve resigned to doing that for the long term health of the hip joint.

Even though I expected to be in rehab, I committed to be the conditioning coach for the local competitive co-ed ultimate Frisbee team. At about 3 months and one week post-op, I started hosting twice a week, early season track workouts. These included a lot of sprinting exercises, like short recovery sets of 6 x70 yard sprints (1:1 run/rest ratio), with 2 minute recoveries in between, 3 sets total in each workout. Since it was spring, the track infield was very soft, lush grass, so I decided to participate in the workouts on the track infield while they ran on the surfaced track. While I didn’t have full range of motion, my strength was good, and I had enough motion to run relatively normally at the 70-75% speed range. I felt as if the plyometric exercises I‘d been doing prepared my muscles for these types of movements, and I only pushed myself to the point where I felt no real pain at all doing it. I did the "sprints" relatively painlessly, although I was sucking wind because it was the first real cardio work I had done beyond the elliptical machine, which I rarely did at sprinters’ pace because I hated sweating all over the equipment! I was a little sore after the first couple of workouts, mostly in the muscles in the front of my hip, rather than in the joint itself. I’d still be able to bike home, and I was fine by the end of the next day. I never took any pain meds or anti-inflammatory drugs during my early recovery process because I figured if I needed them, I was probably trying to do too much. I kept up the 2 a week (soft) track workouts – largely sprinting, with minimal jogging (less than ½ mile to warm up before stretching) for the next 3 weeks. The reason I did as little jogging as possible was because I was more worried about what the repetitive motion of longer distance jogging would do to my joint than with the sprinting, which was bursts of about 10-15 seconds of running on a soft surface. I’m not saying my logic is medically confirmed, it was just the feeling I had. I also continued to do stretching to increase my range of motion on the days I wasn’t sprinting, as well as some low-impact plyometric stretching and strengthening. If I felt any kind of prolonged pain that could cause me to limp, for example, I would take a day or two off, because while I wanted to come back as fast as I could, I didn’t want to do it too fast. I let pain be my guide.

At about 4 months, I began to add a host of higher impact plyometric exercises to my routine – e.g., high knees, hoping, jumping, bounding, although I had been mixing them in, to some degree, for the previous couple of weeks. I also added some change or direction or "cutting" running drills into the sprinting track workouts – like ladder sprints, where you run 10 yrs and back, then 20 and back, and then 30 and back. I continued these on the soft grass and I changed into cleats so that I wouldn’t slip at all on the turns. I eased into these because I wasn’t sure how my body would respond, but it responded well. The worst part is that the operated hip was still stiffer than the good hip, and I didn’t want to create an imbalance in my stride or muscles by sprinting/cutting too hard one way and not the other. So I only did them at the speed that was within my comfortable flexibility range on both legs, which at that time was about 75% of what I would consider maximum. As it turned out, changing direction did not feel hard on the joint, but changing speed (slow to fast) was a bit difficult because it requires different muscles to slow down and speed up quickly, and I realized I needed some time to get those back.

At 4 ½ months post-op, our team had our first 2-day tournament. I didn’t expect to play, as I really hadn’t done any live-action running and cutting other than very controlled drills. However, I convinced our captain, who called the field lines on our team, to put me in for a few points at a position where I was less likely to have to run or chase people all over the field but would still have to make relatively quick cuts and changes of direction (at the "handler" position, for those who know the sport). I wasn’t super fast or quick, but I was okay! The second day, I took a lot more points, and even played some of the tough, final points in a competitive semi-final game. In that game, I found that having to chase around a quicker opponent was stressing the inside groin muscle on the operated leg, so I wisely benched myself for the final game, not wanting to put my progress back.

My groin was sore for a day or two after the weekend tournament, but I continued to stretch it, and found that all the running I had done had really begun to loosen up the joint and extend the range of motion – still not back to normal but closer to 80-85% - I was finally able to bring my knee to my nose while having one leg on the ground and the operated leg bent on the seat of a chair (that had been my goal for about 2 months. To get this flexibility, I found it helpful to do 5 minute deep stretches, which my PT had recommended. This meant that without pushing too hard at once, I could work on elongating the muscles in the joint over time rather than trying to do anything to force them quickly. It seemed to me to be a safer way to increase range of motion. After 5 minutes of the stretch, my leg would sort of get "stuck" in this position, but after I’d slowly ease my leg back down with my arms and set it straight, it would take just several seconds to return to its regular state. I certainly have a new found respect for the resiliency of human musculature!

At about 5 months post-op, which was the Fourth of July weekend 2010, I attended a 3 day ultimate Frisbee tournament in Seattle Washington. It had been my goal from the day I scheduled the surgery to be able to play in this tournament. It’s much more of a "fun" than competitive tournament, so I wasn’t worried about having to impress or play 100% all of the time. We played 3 - 1 ½ hour games each day, over three days, and I played in each game. I started fairly cautiously on day 1, and I did a lot of standard and plyometric stretching exercises before and after the games. I didn’t entirely feel like my old self – I’m usually the person who doesn’t get tired running and jumping around, but I was definitely tired, both in terms of muscles and lung capacity, but that is typical enough given where I was in my rehab. After day 1 and 2, I was sore, but it was the typical sore – hamstring muscles, a little in the hip flexors on both sides, but nothing that different than before the surgery. If anything, my non-operated hip was a bit sorer than the operated one, and this has generally been the case since I started doing more of the "cutting" types of sprinting activities. My assumption about why this is true is because the operated hip does not have full 100% flexibility—and sometimes I do run at 100%--as a result, the other leg has to compensate a bit. That is why I continue to make it a top priority to get as full a range of motion back in the operated hip as I can, and for me it has taken on-going commitment and work. Anyway, by the end of day 3, I was pretty much feeling like my old self – I was sprinting well, cutting well, and jumping well. I was very pleased to hear my teammate say "welcome back" after the final game, when I played as well as anyone on the field, and played a key role in turning at 6-1 deficit into a 9-6 win for our team!

I just got back from the Seattle tournament last night, and I decided to take time to write this long story. I know that in my own process of deciding on the BHR surgery and undertaking rehab, I depended on, and found strength in, the stories of others who have posted on this site. The stories gave me the confidence to go ahead with the surgery and made me believe a strong recovery was possible.

Even though I was very methodological about my recovery process, I would not suggest that others go against their surgeons orders on how to best assure a successful recovery. Medical doctors know much more about stuff than I do. I only know my body, and I listened to it as best I could, and although I pushed it at times, I always pulled back when pain or discomfort told me I should. And I was very good about heeding the post-op restrictions for the first few months of recovery. In the end, I’m very pleased with my recovery to date. My old real worry is about how long the joint may last, because of course no one knows for sure. But being where I am, 5 months post-op, I couldn’t be happier, and I wanted to share my story.

 

My DOB is 03/27/1969.

My History:

I had an auto accident in Dec 1994 and ended up with a broken femur on both legs. They did a IM nailing on both legs.

I have been playing tennis since 1995 till now and play 3-4 times a week. In Jan 2009, I started developing pain in right hip area and I found out that I had a osteo arthritic condition (could be due to trauma from before) and it was literally bone on bone. I took my time to decide on surgery date and continued to play tennis with taking Advil after the games.

Then I consulted Dr. Ratterman in June 2009 and he pretty much came out and said that BHR is the best option for me due to my age. I went back to him in April 2010 to solidify surgery dates and finally got it done on June 16th. Total joint Replacement was also an option on the table but he managed to do BHR. But he also had to remove the screw on top of the IM nailing to make room. So, I am told I will need to be on walker for a month. I am responding to PT really well.

Looking forward to continue to active outdoor life but will do so after I heal well. My surgeon Dr. Ratterman referred me to your site. Your site has been an inspiration to all of us and Keep up the good work!

Regards,
Sriram

Smith & Nephew Press Conference about the Safety and Effectiveness of Hip Resurfacing with the BHR -
Birmingham Hip Resurfacing Device

Review by Patricia Walter

May 6, 2010

Introduction: Joseph M. DeVivo, President of Smith & Nephew Orthopaedics

Joseph M. DeVivo, President of Smith & Nephew Orthopaedics (NYSE: SNN, LSE: SN), the maker of the BHR Hip introduced the press conference and discussed the safety and effectiveness of the BHR.  He explained that over 125,000 patients worldwide have received a BHR since 1998. The BHR and the issue of metal sensitivity in patients with MOM (metal on metal) implants will be discussed. The purpose of this event is to deliver specific facts about the BHR and its unrivaled track record of success for active patients around the world.

Mr. DeVivo explained that information about hip resurfacing presented at the 2010 American Academy of Orthopedic Surgeons will be discussed.  Recently, there has been negative information in the press about metal on metal devices which includes hip resurfacing devices like the BHR.  The press has taken the failures of a few to cast doubts about all hip resurfacing.   It has omitted the successes of hip resurfacing and that 7 out of 10 surgeons performing hip resurfacing choose the BHR.  Smith & Nephew feel the BHR is a safe and effective device providing successful hip resurfacing for patients worldwide.

Derek McMinn, MD, British surgeon and inventor of the BHR

Derek McMinn, MD, pioneering British surgeon and inventor of the BHR hip explained that the BHR has been proven successful by peer review data and his own clinical data. There are four main pieces of evidence that show the success of the BHR:

1.   The Australian Orthopaedic Association's National Joint Replacement Registry - tracked every hip resurfacing since 1998.  Less than 1/3 of 1 percent of hip resurfacing failures are caused by an adverse tissue reaction.

2. In a 9 center Canadian study presented at the recent 2010 AAOS, 3 resurfacing patients out of 3400, less than 1/10 of 1 percent, experienced a tissue reaction.

3. Long Term data, from the Owestry outcome center, tracked 5000 BHR patients and now 518 BHR patients at 10 years of follow up. The study was carried out by 18 surgeons in 16 different countries. There was a 95% success rate at 10 years.

4.  Mr. McMinn’s own clinical data started in 1997.  He performed 3095 BHRs until end of 2009.  At 12 years follow up, he has a 96% survivorship.

Therefore, according to McMinn, those 4 pieces of data from a large number of surgeons and his own clinical experience shows the BHR works.  There have been adverse reactions reported in all of the studies, but these numbers are incredibly small. However, since MOM resurfacing has been going on in UK since 1991, when he did his first resurfacings, there have been a number of adverse reactions reported. One study from Oxford has over 30 presentations or publications of pseudotumors.  In 2008, one percent of their patients were affected by this condition. Mr. McMinn explained that we need to examine what has happened in Oxford. They presented and published 610 BHRs in 2008. Those patients were operated on by 7 consultants and 30 trainees resulting in a large input from inexperienced surgeons. We know, explained McMinn, from a presentation from the last academy meeting that they have reported on poor surgery. The inclination angle of the cup should be 40 degrees; however, the Oxford pseudotumor group reported angles from 10.1 to 80.6 degrees.  I need to stress, the high inclination angles up to 80.6 angles are completely unacceptable. Every BHR, Metal on Metal, Ceramic on Ceramic and metal on poly device will fail with that type of poor surgery.  

McMinn explains that the adverse reactions for hip resurfacing are reported from 2 categories:

1. Poor results from well established BHRs put in badly causing edge loading, high metal wear and an adverse tissue reaction to lots of debris.

2. Poor results from implants that don’t work. The  4^th generation devices such as the Durom and ASR devices have both been associated with much higher failure rates than the BHR both on individual surgeon reports and Australian national registries. The adverse tissue reactions to the ASR are particularly prevalent. The UK reports around 7% revision rate for ASR resurfacing.  ASR THR mom failures are also double than other devices.  So the UK regulatory bodies are faced with reports of devices that are poor and adverse tissue reactions by well established devices put in badly.

Edwin Su, MD, of the Hospital for Special Surgery

Edwin Su, MD, of the Hospital for Special Surgery, agreed about the importance of hip resurfacing in the lives of patients.    After training with Mr. McMinn and Dr. Amstutz, he has completed over 1300 hip resurfacings with majority being BHRs.  I can say with authority that this procedure can be a life restoring event for the patients. Metal on Metal hip resurfacing done with precise technique and a well designed implant can work.  In appropriate patients, hip resurfacing can achieve nothing short of miraculous life changing results.  Hip resurfacing allows patients to return to active pain free lives. Certain patient types do better with resurfacing than others.  Good solid bone stock means you will do well.  Poor bone stock means there is an elevated risk of a femoral neck fracture. This is common knowledge    Patients under age 65 have best bone stock.  92.7% of all resurfacings are in patients under 65.  Patient selection is very important.  The data shows men do better than women.  Women require smaller components and are more difficult to align during surgery.  Also women’s bones are less dense, so some women are not ideal candidates for hip resurfacing. Australian shows 80% resurfacings are in men.  Resurfacing works better in men than women. Women of child bearing years are not recommend to have hip resurfacing.

Dr. Su explained about the issue of Implant alignment.  If the components are misaligned, there will be an increased risk of metal wear because the surfaces will not be properly lubricated during regular physical activity. There is a resulting risk of adverse tissue reactions and possible revision surgery.  Although this is true for most hip replacement surgery, it is especially true for resurfacing since the implants are less forgiving due to their precise manufacturing.  This rate of adverse tissue reactions is extremely rare in resurfacing and less than ½ of 1 percent.

The literature, explained Dr. Su, shows experienced surgeons who have undergone appropriate training, can place a hip resurfacing device correctly.  A surgeon not doing them on a regular basis has a greater chance of not achieving optimal results. It’s that simple explained Dr. Su.   This is true in any surgery in any specialty. While some implants perform better than others, good outcomes with hip resurfacing most often are achieved by experienced surgeons who have received excellent training and are careful in patient selection.  Dr. Su has offered hip resurfacing since 2006 and has seen spectacular results since then.

Scott Marwin, MD, an orthopedic surgeon with New York University's Hospital for Joint Diseases

Dr.  Marwin explained that the use of the BHR, after 12 years use worldwide and 4 years use in the states, remains an exciting option for some patients.  It has never been suggested for all hip replacement surgery.  Fewer than 10% of all patients are candidates.  Fundamentally, it is a bone conserving procedure and saves a significant amount of healthy bone.  Preservation of the basic structure of femur retains the natural size and angles of the joint and reduces any possibility of leg length discrepancy after surgery.  Also patients’ soft tissue doesn’t have to adjust to a different set of shapes and kinematics that comes with a THR. Many patients forget which side has the BHR implant.  Hip resurfacing also retains the patient’s anatomy which decreases the possibility of a dislocation. In a THR, the long metal neck can act like a lever on the edge of the metal cup and dislocate the ball out of the socket.   The natural femoral neck retained during hip resurfacing means incidence of dislocation is extremely rare.  If a resurfacing patient needs a revision, they can receive a matching THR component to match the existing cup.  Hip resurfacing reduces wear and leads to a longer life for the implant as compared to a THR.  Dr. Marwin has implanted more than 750 hip resurfacing devices and can see what they can do for the active patient.

 

Summary by Joseph M. DeVivo

 The BHR is different than other MOM devices on the market that are not performing up to standard. The BHR outperforms the gold standard for THRs in the core patient age group. Hip resurfacing gives patients their active life style back.  BHR preserves so much healthy bone that it feels like a normal hip. More information can be found a www.hipsresurfacing.com

Question and Answers from Audience

Question:  Terry Stanton, AAOS.  Concerning the medical device alert in Britain - is it warranted and correctly crafted?

Answer: Dr. Su - It casts a general concern over MOM usage, but does not speak specifically to the BHR.  BHR has its own clinical data and has not produced the type of concern other MOM device have.  It stands on its own according to worldwide sources.

Q: Surgeon inexperience and poor technique – more globally in the US, what factor will it play?

A:  Dr. Su - Where the BHR is concerned, as part of the FDA approval, it has mandated a very high level of training.  Every surgeon is trained to same protocol.

Q: Canadian Study presented in New Orleans – follow up was 3 years. Comment on how solid the evidence is since the follow up is shorter.

A.  Mr. McMinn - Important to look at what happens in first 3 years in hands of a new group of surgeons to hip resurfacing.  The Oxford Group is reporting adverse reactions to metal debris in the early years. It is highly significant how a new group of trained surgeons get on.  The fact that there are an incredibly low number of incidents of adverse reactions in a 9 center study with over 3000 patients speaks volumes for the devices and training of the surgeons.  The longer term results are more important. The Australian registry has over 8000 people with an incredible low incidence of adverse reactions with survivorship at  95% for BHR at 8 years.  The Oswestry registry with 518 patients at 10 years, shows a  95.4% implant survivorship.  Phenomenally good results.  In my own group, adverse reactions have occurred in 0.3% of my whole group.  Out of 3095 BHR patients thru 2009, there were 10 adverse reactions.  Unlike the Oxford Group, all the revisions have been fine. None were associated with soft tissue destruction.  These were in the main, fluid collections requiring a bearing change to solve the problem. The patient made a totally uncomplicated recovery.  I saw adverse reactions much later.  Oxford was showing them 2 or 3 years after surgery. 

Q. Metal sensivity and pseudotumros are always curious problems.  In terms of devices, is there is less metal release in different devices?

A. Mr. McMinn - It is very clear who gets the pseudotumors. The retrievals from the Oxford Group show pseudotumors were associated with aged wear of the acetabular cup.  With normal lubrication and normal wear, there are no pseudotumors.  Clearly,  if you want a MOM device to fail,  implant it badly or design it badly so you get age loading and age wear which results in a high metal volume of debris early on.

New Data Reinforces the Proven Safety and Effectiveness of the BIRMINGHAM HIP Resurfacing System

80-percent of US surgeons choose the BHR hip as it outperforms all other metal-on-metal resurfacing devices

MEMPHIS, Tenn., May 3 /PRNewswire-FirstCall/ -- Recent new data(1) presented at this year's American Academy of Orthopaedic Surgeons (AAOS) annual meeting reinforces the BIRMINGHAM HIP™ Resurfacing (BHR) System as a safe and effective hip resurfacing device. The multi-site study, performed by orthopedic surgeons practicing at nine Canadian academic centers, showed that three years after surgery, 99.91% of their 3,400 hip resurfacing patients experienced no implant failure due to metal wear debris. The BHR Hip was the most used resurfacing device in this study.

This week, the Hospital for Special Surgery (HSS) in New York City will be holding a medical education course titled "Total Hip: Replacement and Resurfacing" on May 7 and 8 for leading hip surgery specialists from across the U.S. Chairing the course will be Edwin Su, MD, of the Hospital for Special Surgery, and the teaching faculty will include pioneering British surgeon Derek McMinn, MD, inventor of the BHR hip.

During a press conference and Q&A webcast on Thursday, May 6, at 3 p.m. US EDT, 8 p.m. GMT, Joseph M. DeVivo, president of Smith & Nephew Orthopaedics (NYSE: SNN, LSE: SN), the maker of the BHR Hip, will be joined by Dr. Su and Mr. McMinn, as well as Scott Marwin, MD, an orthopedic surgeon with New York University's Hospital for Joint Diseases. The panel will review current data confirming the safety and effectiveness of hip resurfacing and the BHR Hip. Smith & Nephew Orthopaedics will host the call, and additional details are at the bottom of this release.

The new study recently presented at the AAOS meeting aligns with previously released BHR Hip data from other prestigious sources and further addresses the metal wear debris concerns raised about metal-on-metal hip implants.  The BHR Hip's track record for longevity remains unchallenged in the literature, as well. These sources include:

• The Journal of Bone and Joint Surgery published in January of this year a study tracking 155 consecutive BHR patients over three years. The data showed no revisions of BHR Hips due to metal wear, but patients who received a competing metal-on-metal resurfacing device were revised within three years of surgery at a rate of 3.4-percent due to adverse tissue reactions.(2)
• The Australian Orthopaedic Association's 2008 National Joint Replacement Registry, a record of nearly every hip implanted in that country over the previous 10 years, tracked 6,773 BHR Hips and found that less than one-third of one-percent may have been revised due to the patient's reaction to the metal component.(3)  
• The Australian Registry hip resurfacing data for 2009, 70-percent of which comes from BHR Hip procedures, indicates that for men under age 65, hip resurfacing performs at the same or a better rate than total hip replacement. This registry also shows that the BHR Hip remains successful in 95-percent of cases eight years after surgery, whereas no other implant performs better than 94.7-percent just five years after surgery.(4)
• Great Britain's Oswestry Outcomes Centre's patient registry,  which tracked 5,000 BHR Hips implanted by 148 different surgeons in 37 countries over 10 years (1998-2008), reports that the BHR Hip remains successful in 95.4-percent of all patient segments 10 years after surgery. This registry also reported that 98.6-percent of patients were "pleased" or "extremely satisfied" with their BHR Hip implants 10 years after their resurfacing procedure.(5)
• Mr. McMinn's clinical data, based on 3,095 hip resurfacing patients implanted between 1997 and 2009, shows that more than 12 years after surgery, the BHR hip remains successful in 99-percent of men aged 60 and over, and 97-percent for men under age 60.

"The BHR Hip's outcomes are remarkable when compared to other resurfacing devices," said Dr. Marwin. "The depth and consistency of the data collected globally shows the BHR Hip is truly different."

"For the right patients in my practice, hip resurfacing has proven to be an excellent choice," said Dr. Su. "They have extremely high levels of satisfaction after returning to their regular lifestyle."

To explain the patient advantages seen consistently in the literature, surgeons indicate the key differences between the BHR Hip and other resurfacing devices are its metal composition, its design geometry and its surgical instrumentation.

The BHR Hip has a unique metallurgy heritage which goes back more than 30 years and includes a first-generation metal-on-metal resurfacing process which contributes to long-term survivorship of BHR Hip recipients.

Additionally, the BHR Hip's design geometry replicates the natural hip's ability to pull the body's own joint fluids into the ball and socket interface, which is believed to be another source of its best-in-class performance.

Of particular importance during hip resurfacing surgery is the correct positioning of the acetabular cup, or hip socket. When this component is not properly aligned, studies show that metal wear can accelerate and resurfacing devices can fail before their time.  Surgeons believe that the instrument used to implant the BHR Hip is simpler and more accurate than other devices' instruments, and may contribute to its success.

"Just like the lubricating barrier in a healthy hip, there is a natural fluid layer between the femoral head and the cup that the two metal surfaces glide across during physical activity," said Mr. McMinn. "If the surgeon malpositions the acetabular cup causing edge loading, the lubrication is lost. It's equivalent to running a car engine without lubrication oil. High wear will occur, resulting in premature failure. Overall, it is a combination of the metal composition, the design and the quality of the surgical technique that makes the BHR Hip the safest resurfacing implant on the market."

"The bottom line is that the BHR Hip is not like other metal-on-metal hip implants," said DeVivo. "Not only does it have the longest track record of any resurfacing device, but the most esteemed medical literature shows it outlasts other implants. It's in a class all its own – it's safe and effective, and is the best choice for active patients."



Footnotes

(1) Beaule PE, Smith FC, Powell JN et al. A Survey on the Incidence of Pseudotumours with MOM Hip Resurfacings in Canadian Academic Centres. Podium presentation # 665. Proceedings of the American Academy of Orthopaedic Surgeons Annual Meeting, New Orleans LA. 2010

(2) Langton DJ, Jameson SS, Joyce TJ, Hallab NJ, Natu S, Nargol AVF.  Early failure of metal-on-metal bearings in hip resurfacing and large-diameter total hip replacement, A CONSEQUENCE OF EXCESS WEAR. J Bone Joint Surg Br. 2010; 92-B: 38-46

(3) Table HT 46. Australian Orthopaedic Association National Joint Replacement Registry Annual Report. Adelaide: AOA; 2008.

(4) Table HT 46. Australian Orthopaedic Association National Joint Replacement Registry Annual Report. Adelaide: AOA; 2009.

(5) Robinson E, Richardson JB, Khan M. MINIMUM 10 YEAR OUTCOME OF BIRMINGHAM HIP RESURFACING (BHR), A REVIEW OF 518 CASES FROM AN INTERNATIONAL REGISTER. Oswestry outcome centre, Oswestry, UK.

About Us

Smith & Nephew is a global medical technology business, specialising in Orthopaedics, including Reconstruction, Trauma and Clinical Therapies; Endoscopy and Advanced Wound Management.  Smith & Nephew is a global leader in arthroscopy and advanced wound management and is one of the leading global orthopaedics companies.

Smith & Nephew is dedicated to helping improve people's lives.  The Company prides itself on the strength of its relationships with its surgeons and professional healthcare customers, with whom its name is synonymous with high standards of performance, innovation and trust.  The Company operates in 32 countries around the world.  Annual sales in 2009 were nearly $3.8 billion.

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Staples significantly increase risk of postoperative infection study

March 2010 Original Link  http://www.orthosupersite.com/view.aspx?rid=62584

The use of staples to close wounds following orthopedic surgery - especially hip surgery - is associated with a significantly greater risk of wound infection than traditional suturing, according to orthopedic researchers from Norwich, England.

Six clinical trials

Toby O. Smith, MSc, BSc (Hons), MCSP, and colleagues analyzed the results of six trials that compared staples and sutures used for wound closure following orthopedic procedures in adult patients. The six clinical trials involved 683 wounds. Of these cases, 322 patients underwent suture closure and 351 patients had staple closure, according to a British Medical Journal press release.

The authors found that wounds closed with staples were more than three times as likely to develop a superficial wound infection compared to wounds closed with sutures. In a subgroup analysis of patients undergoing hip surgery, the risk of developing a wound infection was found to be four times greater after staple closure than suture closure, according to the release.

Staples not recommended

The researchers found no significant difference between staples and sutures in the development of inflammation, discharge, dehiscence, necrosis and allergic reaction.

The authors called for high quality, well-designed trials to confirm their findings.

Although the quality of evidence from the six trials was generally poor, the authors concluded, "With the current evidence, however, patients and doctors should think more carefully about the use of staples for wound closure after hip and knee surgery."

•Reference:
Smith TO, Sexton D, Mann C, et al. Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis. BMJ. [Published online ahead of print March 16, 2010]

A Modified Posterior Approach Preserves Femoral Head Oxgenation During Hip Resurfacing 2010

Steffen RT, De Smet KA, Murray DW, Gill HS  2010 Mar 22

Original Link  http://www.ncbi.nlm.nih.gov/pubmed/20334994?dopt=AbstractPlus

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK.

In 11 patients, the oxygenation was measured in the superolateral quadrant of the femoral head during resurfacing with a modified posterior approach, designed to preserve the blood supply, using a gas-sensitive electrode. These were compared with measures from 10 patients in whom the standard posterior approach was used. The modified approach patients maintained a significantly (P < .005) higher amount of relative oxygenation after the approach, 78% (standard deviation [SD], 45%) vs 38% (SD, 26%), and acetabular component implantation, 74% (SD, 56%) vs 20% (SD, 28%). The modified posterior approach, unlike the standard extended approach, does not significantly compromise the blood supply to the head; and we recommend this approach be considered for hip resurfacing.

Does commitment to rehabilitation influence the clinical outcome of total hip resurfacing arthroplasty study 2010

Link to original medical study

The purpose of this study was to evaluate whether compliance and rehabilitative efforts were predictors of early clinical outcome of total hip resurfacing arthroplasty.

Methods: A cross-sectional survey was utilized to collect information from 147 resurfacing patients, who were operated on by a single surgeon, regarding their level of commitment to rehabilitation following surgery. Patients were followed for a mean of 52 months (range, 24 to 90 months).

Clinical outcomes and functional capabilities were assessed utilizing the Harris hip objective rating system, the SF-12 Health Survey, and an eleven-point satisfaction score. A linear regression analysis was used to determine whether there was any correlation between the rehabilitation commitment scores and any of the outcome measures, and a multivariate regression model was used to control for potentially confounding factors.

Results: Overall, an increased level of commitment to rehabilitation was positively correlated with each of the following outcome measures: SF-12 Mental Component Score, SF-12 Physical Component Score, Harris Hip score, and satisfaction scores.

These correlations remained statistically significant in the multivariate regression model.

Conclusions: Patients who were more committed to their therapy after hip resurfacing returned to higher levels of functionality and were more satisfied following their surgery.

Author: David MarkerThorsten SeylerAnil BhaveMichael ZywielMichael Mont
Credits/Source: Journal of Orthopaedic Surgery and Research 2010, 5:20

Sports Activity After Total Hip Resurfacing Study 2010

Original Link http://www.ncbi.nlm.nih.gov/pubmed/20223940?dopt=Abstract

March 11, 2010

Banerjee M, Bouillon B, Banerjee C, Bäthis H, Lefering R, Nardini M, Schmidt J.
Dreifaltigkeits-Krankenhaus and Cologne Merheim Medical Center.

BACKGROUND: Little is known about sports activity after total hip resurfacing.

HYPOTHESIS: Patients undergoing total hip resurfacing can have a high level of sports activity. STUDY DESIGN: Case series; Level of evidence, 4.

METHODS: The authors evaluated the level of sports activities with a standardized questionnaire in 138 consecutive patients (152 hips) 2 years after total hip resurfacing. Range of motion, Harris hip score, and Oxford score were assessed, and radiological analysis was performed.

RESULTS:  Preoperatively, 98% of all patients participated in sports activities. Two years postoperatively, 98% of the patients participated in at least 1 sports activity. The level of sports activity decreased after surgery. The number of sports activities per patient decreased from 3.6 preoperatively to 3.2 postoperatively. Intermediate- and high-impact sports, especially tennis, soccer, jogging, squash, and volleyball, showed a significant decrease while the low-impact sports (stationary cycling, Nordic walking, and fitness/weight training) showed a significant increase. Physical activity level at the time of follow-up as measured by the Grimby scale was significantly higher than in the year before surgery. Duration of sports participation per week increased significantly after surgery. Men had a significantly higher sport level than women before and after surgery. Eighty-two percent felt no restriction while performing sports. One-third missed certain sports activities such as jogging, soccer, tennis, and downhill skiing. The Harris hip and Oxford scores showed a significant increase postoperatively.

CONCLUSION: The results of this short-term follow-up study show that sports activity after total hip resurfacing surgery is still possible. Physical activity level increased with a shift toward low-impact sports. Duration of sports participation increased. High-impact sports activities decreased. These findings  can be important for the decision-making process for hip surgery and should be communicated to the patient.

I had my left hip resurfaced by Dr. Clarke on April 30, 2008 using the Birmingham hip. Prior to that I had been in physical and aqua therapy for nearly a year, attempting to retain range of motion and strength. My recovery after surgery was very quick. I walked without a cane in less than 3 weeks, and mowed my lawn with a self-propelled walking mower at 3 weeks. All the time I was diligent about my exercise program from my PT. The progress was amazing with noticeable improvement from one day to the next. In a month I was able to walk around my neighborhood (a little over a mile), something I had not been able to do in a couple of years.

In fact I was so pleased with the success of my left hip that I had my right hip done on July 23, 2008. Since it was not as debilitated or weak that side bounced back even faster! The surgery itself was very quick, about an hour, and because of my fitness on that side I noticed ability to move right away that was not present on the previous hip.

For both operations I stayed in Community General Hospital, where the care was outstanding. On the orthopedic floor they have many private rooms, and I was fortunate to be assigned to a private both times. The follow up care through Dr. Clarke was also top notch. My questions were always answered, and everyone was easy to talk to.

I am a teacher, and plan to return to my classroom ready to roll in September. Can't wait to do my job without pain.

Long story short, if you are considering this procedure, don't wait until things are terrible in your joints. Also try to prepare your body with exercise prior to surgery.

You will find it helps you to recover faster and with less pain. I feel blessed to have Dr. Clarke with this groundbreaking procedure, in the area, although I would definitely travel to obtain this care.

Linda Ward