Tuesday, June 17. 2008
AAOS SAN FRANCISCO, March 7, 2008 - Some of the purported advantages of hip
resurfacing over standard arthroplasty, though not all, seem to be real,
researchers found in a randomized trial.
But other pluses in activity and function can probably be chalked up to patient
selection bias and expectations, reported Martin Lavigne, M.D., of the
University of Montreal, and colleagues, at the American Academy of Orthopaedic
Surgeons meeting here.
In the randomized trial, patients who had hip resurfacing were significantly
more likely to return to work and sports and had better step and hop test scores
than standard arthroplasty patients did.
But functional scores and range of motion were no better than with hip
replacement, the investigators found.
Hip resurfacing gained popularity with patients and some orthopedic surgeons on
the basis of assumptions about better clinical function and ability to return to
a high level of activity.
While retrospective cohort studies reinforced this perceived benefit, Dr.
Lavigne said, "obviously there was a bias in the patient selection for hip
resurfacing." Patients who sought hip resurfacing tended to be younger, more
active, healthier, and expected a more active life after surgery, he said.
The newer procedure is still controversial among orthopedic surgeons despite
rapid increases, commented Tom Schmalzried, M.D., of the Orthopaedic Hospital in
Los Angeles, in a press conference where there was debate over the two
approaches.
"The results of good, modern total hip replacement are really, really good," he
said. "So for resurfacing to have a favorable risk-to-benefit ratio, you have to
show you are getting something you don't get with total hip replacement."
For a more objective answer to this issue, Dr. Lavigne's group randomized 210
patients who were candidates for either procedure to undergo either uncemented
28-mm metal-on-metal total hip arthroplasty or hybrid metal-on-metal hip
resurfacing.
All procedures were done by the same three surgeons with a posterior approach.
Patients were informed which surgery they underwent only afterward.
Patients had a mean age around 50. Body mass index was higher in the total hip
arthroplasty group.
Functional scores were slightly worse in the hip replacement group at six months
(17 versus 11 on the WOMAC scale) but identical by two years (5 for both).
At six months after surgery, hopping on the affected leg was significantly
easier for resurfacing group patients ("easy" or "very easy" 91.7% versus 78.9%
and "difficult" or "impossible" 8.3% versus 21.1%, P=0.023).
Likewise, climbing stairs in a step test was easier at six months in the
resurfacing group compared with the replacement group ("easy" or "very easy"
94.4% versus 76.3% and "difficult" or "impossible" 5.6% versus 23.7%, P=0.015).
Hip resurfacing group patients were also more likely to return to their prior
work (96% versus 83%, P=0.02).
The young age of the patients made this an important outcome, Dr. Lavigne said.
Among the patients, 152 had data on activity level pre- and post-procedure.
Despite similar activity levels before surgery (P=0.22), more hip resurfacing
than hip replacement patients returned to sports activities by one year after
surgery (15% versus 7% high impact and 38% versus 28% moderate impact activity,
P=0.022).
On a scale that included activities of daily living as well as sports, the
difference tended to favor hip resurfacing but was not significant at one year
(P=0.074).
"Both groups returned to a high level of activity," Dr. Lavigne said. "Hip
resurfacing patients seem to be more active, but not as much as expected."
Type of surgery had no significant impact on what factors patients reported as
limiting their return to sports activities, including implant protection,
discomfort, fear of instability, and thigh pain.
Hip range of motion -- including total arc, arc of rotation, flexion-extension
arc, and abduction-adduction arc -- was also similar for both groups among the
122 patients with data on this outcome (P>0.05).
Satisfaction with the procedure was uniformly high over time and across
treatments.
While resurfacing is a more aggressive technique, Dr. Lavigne said, the rate of
complications was similar between groups.
Long-term follow-up will be important to determine whether there are differences
in need for revision between the procedures, he concluded.
Dr. Lavigne reported receiving research or institutional support from Zimmer,
Stryker Howmedica, Biomet, DePuy, and Smith & Nephew and consulting for Zimmer.
Dr. Schmalzried reported receiving research or institutional support from
Stryker, DePuy, Johnson & Johnson, Corin, and Wright Medical Technology;
receiving miscellaneous funding from Stryker, DePuy, Johnson & Johnson, Corin,
Wright Medical Technology, Zimmer, and Smith & Nephew; receiving royalties from
Stryker, DePuy, Johnson & Johnson, Corin, and Wright Medical Technology; holding
stock options in Stryker, DePuy, Johnson & Johnson, Corin, Wright Medical
Technology, Zimmer, Biomet, Bristol-Myers Squib, and Pfizer; and being a
consultant for Stryker.
Primary source: American Academy of Orthopaedic Surgeons meeting
Source reference:
Lavigne M, et al "Range of motion after hip resurfacing and THA: A single-blind
randomized clinical study" AAOS meeting 2008; Abstract 058.
Additional source: American Academy of Orthopaedic Surgeons meeting
Source reference:
Lavigne M, et al "A randomized study comparing surface replacement arthroplasty
to total hip arthroplasty" AAOS meeting 2008; Abstract 056.
Additional source: American Academy of Orthopaedic Surgeons meeting
Source reference:
Lavigne M, et al "Return to sports after hip resurfacing and total hip
arthroplasty: A randomized clinical trial" AAOS meeting 2008; Abstract 053.
Tuesday, June 17. 2008
Link
http://www.argusleader.com/apps/pbcs.dll/article?AID=/20080616/LIFE/806160306/1004/life
Ken Kuipers' hip pain started in 2006. At first, the 51-year-old Platte
farmer tried to tough it out.
Even though a couple doctors recommended hip replacement, Kuipers wasn't ready
to give in.
"I wanted to keep my own joint as long as possible," he says.
Doctors told him he could try cortisone injections, but Kuipers ruled that out
because the shots were expensive and provided temporary relief. He needed to
keep up with his animals and field work, so when the pain didn't ease up, Dr.
Matthew McKenzie, orthopedic surgeon at the Orthopedic Institute, offered
another option.
Kuipers was a perfect candidate for hip resurfacing, McKenzie says. People who
are active, younger than 65 and have normal bone tissues have the best chance
for success with the procedure, he says.
Doctors also consider the expected life span of the patient before deciding on
the type of surgery performed. Hip replacements don't last forever.
"There is about a 20 percent failure rate in 25 years, depending on what study
you're looking at," McKenzie says.
He has done the resurfacing procedure for about nine months, something that
Orthopedic Institute added because patients were going out of town to have the
surgery, he says.
A hip resurfacing procedure has the same goal as a standard total hip: Pain
alleviation. Contrary to popular belief and Internet promises, the procedure is
not less invasive or expensive nor does it mean a shorter recovery time.
With hip resurfacing, Kuipers faces six weeks of healing, the same time a total
hip replacement would have taken. The newer surgery is not cheaper because new
technology always costs more, McKenzie says.
The main reason to have a hip resurfacing is because it means less bone removal.
"If it fails, you can revise it to a standard total hip," he says. "Anything to
save bone is the right thing to do."
During a hip resurfacing procedure, the ball of the hip is machined down, a
metal cap is fitted over it and a short anchoring spike is driven down the
femur. The neck of the femur is preserved as well as much of the ball. The
position of the implant and the patient's muscles hold the hip in place.
In a traditional hip replacement, the entire ball and joint is removed and
replaced with an artificial joint, and a long rod is placed in the femur.
Kuipers' incision is 10 inches long, that compared with a hip replacement that
is typically half that or less.
He was in the hospital for several days. He had the surgery on a Wednesday and
went home Saturday. He had two physical therapy sessions on Thursday and Friday
while in the hospital, says his wife, Donna. They taught him stretching and
strengthening exercises to do at home.
He's using a walker right now.
"I'm just about ready to switch to a cane," he says.
The pain is better but different, he says. It's surgical pain from the muscles
being cut. And he still needs pain pills to sleep.
At two weeks post-op, he had his first office visit where his staples were
removed and his incision was looked over. Healing is progressing, and McKenzie
gave permission to increase activity as tolerated.
"I was given the go ahead to get on a tractor," Kuipers says.That's exactly what
he plans to do as soon as it dries out enough to get in the fields.
Tuesday, June 3. 2008
Hip, knee implant makers agree to pay $311M settlement
Link
http://blog.nj.com/ledgerupdates/2007/09/hip_knee_implant_makers_to_pay.html
Posted by John P. Martin and Jeff Whelan September 27, 2007
The nation's largest manufacturers of hip and knee implants today agreed to
pay $311 million to settle allegations that they bribed top surgeons to
recommend their products.
Agents gathered evidence that orthopedic surgeons routinely accepted lavish
vacations, gifts and annual "consulting fees" as high as $200,000 from medical
device makers in return for endorsing their implants or using them in
operations.
The 30-month investigation, headed by federal prosecutors in New Jersey, marks
one of the larger settlements of its kind and follows a wave of cases to
spotlight questionable ethics within the health care industry.
"With these agreements in place, we expect doctors to make decisions based on
what is the best interest of their patients - not the best interest of their
bank account," U.S. Attorney Christopher Christie said in a statement.
The agreements covered five firms, including DePuy Orthopaedics, a subsidiary of
New Jersey-based Johnson and Johnson. Together, the companies control more than
90 percent of the U.S. market in reconstructive implants, a billion-dollar field
expected to surge in coming years.
Three of the manufacturers -- DePuy, Zimmer Holdings and Biomet, Inc. -- are
based in Warsaw, Ind. The others are Stryker Corp., of Kalamazoo, Mich. and
Smith and Nephew PLC, of London.
The civil settlements ranged from $169 million for Zimmer to $26.9 million for
Biomet, based in part on the market share of each defendant, authorities said.
Stryker will not pay any money.
In criminal complaints filed in federal district court in Newark, the companies
admitted paying surgeons consulting fees that violated the federal Medicare
Fraud Statute. The law prohibits companies from offering inducements to doctors
who participate in Medicare. About two-thirds of the 700,000 knee and hip
replacement surgeries performed each year are covered by Medicare.
As part of the agreement, each will also pay for a federal monitor to supervise
their practices for 18 months. The monitors include former U.S. Attorney General
John Ashcroft and the former U.S. Attorneys for New York and Los Angeles.
Monday, June 2. 2008
Dr. De SmetVicky Marlow,
Patient Advocate/Technical Contributor, asks "What is your
opinion on cementless devices for resurfacing?"
Maybe they are good, but we do not know yet. Cement is a shock
absorber between prosthesis and bone or between prosthesis/
bone+cement/ bone, so maybe a good thing, certainly taking in
account that Chrome Cobalt has not the same elasticity as bone
and is quite stiff!
So
Greetz
KOEN
Read More Doctors Opinions About Cementless Hip Resurfacing Here
Friday, May 23. 2008
Friday, May 23. 2008
Friday, May 23. 2008
Dr.
Bob Arnot's Bilateral BHRs with Dr. Su
Read Dr. Bob's Complete Story by Clicking Here
As a television medical
correspondent for decades on shows like Today,
Dateline and the CBS evening News and author of 12
books on consumer medicine, I have to admit it. I
have never faced a more vexing decision than
choosing between a total hip replacement and hip
resurfacing. The claims and data appeared wildly
contradictory and each surgeon’s take was miles
apart from the others...
...I called great friends in
orthopedics at the leading Harvard hospitals and in
NY, Baltimore and Los Angeles. The word I got was
emphatic. Don’t do the hip resurfacing, it’s a
failed concept. It failed in the 70s and its doomed
to fail again...
...I began reading the entire world
literature. I called doctors in France, England,
Belgium, Germany. The more I read, the less I seemed
to know...
...Then I came upon
Surface Hippy Website and read everything on it...
...I went back over my notes, reread
the literature and it suddenly became incredibly
clear. What did I really want?
...The decision ended up being a no
brainer. Hip resurfacing with two BHRs .
READ MORE
Friday, May 23. 2008
Monday, May 12. 2008
Hip resurfacing helped triathlete compete again
Link
www.dallasnews.com
The patient before: Michael Montgomery, 33 years old, of Trophy Club was a
31-year-old Ironman triathlete.
For more than three years, triathlons offered him some semblance of normalcy.
Most of his life revolved around a stressful job in which he traveled the
country as a business-applications consultant.
That is, until he began having intolerable hip pain after the 2006 Ironman
Arizona. In four months, he went from finishing a marathon to being unable to
run a 5K.
An old hip injury from his college wrestling days probably caused avascular
necrosis, a condition following the loss of blood supply that resulted in his
hip tissue dying and the bone collapsing.
Initially, Mr. Montgomery thought total hip replacement was his only choice and
that he would never run again. Through research, he learned that cyclist Floyd
Landis of Tour de France fame had a similar diagnosis and had undergone a newly
approved option using the Birmingham Hip Resurfacing System.
Dr. Jay Mabrey, chief of orthopedics at Baylor University Medical Center at
Dallas, had just become certified to use the device. He had chaired the Food and
Drug Administration Orthopaedic and Rehabilitation Devices Panel, which approved
the implant in May 2006.
It's riskier than total replacement and appropriate only for young, active
patients.
The patient now: Six months after the procedure, he completed the April 2007
Ironman Arizona.
What is it? The Birmingham Hip Resurfacing System preserves more bone than total
hip replacement. It's similar to a tooth cap. Doctors shave and cap a few
centimeters of the bone within the joint with a metal implant rather than
replacing the entire joint.
Why he chose it: Mr. Montgomery wanted to resume running. A total hip
replacement device can't withstand the impact of running.
What you need to know: The Birmingham Hip Resurfacing System has a higher
failure rate than total hip replacement. Total hip replacement makes sense for
most people who are content to do low-impact activities.
Collapsing bone threatened to sideline triathlete Michael
Montgomery (left),
but a hip resurfacing procedure returned him to competition.
He and
Dr. Jay Mabrey examine his X-rays.
Thursday, May 8. 2008
Resurfacing emerges as possible option to hip replacement
By Mary Jo Feldstein
ST. LOUIS POST-DISPATCH
05/07/2008
Read Complete Story Here
The procedure gives many patients the chance to relieve pain and stay active.
Physicians caution their peers to select patients carefully and make sure
they're capable of performing the complicated procedure.
"Patients should have a long discussion with their physician," said Dr. Jay
Mabrey, chief of orthopedics at Baylor University in Dallas and chairman of the
Food and Drug Administration panel that reviews orthopedic devices. "I spend
more time in my practice talking people out of hip resurfacing than talking
people into it."
Such restraint can be difficult as a few device makers put their marketing teams
in gear to maximize this latest profit center.
Hip replacements typically only last two or three decades, leaving young
recipients with few options for their golden years. Hip resurfacing, on the
other hand, can preserve enough healthy bone for a hip replacement later on in
life.
Here's the difference: During traditional hip replacement, both the head and
neck of the femur, or thigh bone, are removed and replaced with metal or plastic
implants. During hip resurfacing, the head of the femur is resurfaced with a
metal hip "joint" and the rest of the thigh bone is left intact.
Patients who opt for hip resurfacing often return to some strenuous physical
activity after surgery.
Goodman hasn't completed another marathon since his surgery a year ago, but he
occasionally jogs shorter distances and he regularly attends high-energy
spinning classes.
He isn't hip resurfacing's only cyclist. Professional cyclist Floyd Landis
underwent the procedure before his contested Tour de France victory.
Resurfacing costs more than a traditional hip replacements, with a price tag of
$10,000 to $12,000 versus about $8,000.
Patients, on average, have similar recovery times. Hip resurfacing patients who
get better faster, generally do so because they were younger and healthier
before the surgery than the average hip replacement patient, said Dr. Robert
Barrack, an orthopedic surgeon with Washington University Orthopedics at
Barnes-Jewish Hospital.
Hip resurfacing is not for everyone. Barnes-Jewish considers it ideal for active
men and women under age 60. People with osteoporosis, diabetes and women who
plan to have children are among the other classes of patients warned to stay
away.
Patients also need to find a qualified physician. Since it was only approved by
the Food and Drug Administration two years ago, few surgeons are proficient in
performing the procedure, which is considered more difficult than hip
replacement.
Barrack said it takes about 50 cases to consistently achieve the best results.
Because only 10 percent of patients qualify for resurfacing, Barrack estimates a
surgeon would have to see 500 patients to reach the threshold.
That's a high volume of patients for a physician outside of a large medical
center, Barrack said. He is a paid consultant for Smith & Nephew, a maker of hip
resurfacing products, though the expertise he provides the company is related to
other products.
Smith & Nephew's Birmingham Hip was the first FDA approved hip resurfacing
product in the United States. It's been a solid product for the British company,
driving growth in revenue and profit. The hip replacement market is worth about
$2 billion, but Smith & Nephew had controlled hip resurfacing's estimated $20
million slice of the pie. Now, as other device makers work through the approval
process, Smith & Nephew is facing new competition.
A concern is whether efforts by device makers to increase the market will
encourage physicians with less experience to perform the procedure or recommend
it to the wrong patients.
Mabrey said he's keeping this procedure for the most active of patients. A
recent example is a triathlete who completed an Ironman competition a few months
after surgery.
"That's the kind of person I aim for," Mabrey said.
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