Doctors

The controversy regarding adverse wear in metal-metal bearings

Thomas P. Gross , MD 3/5/2010

I have used over 3000 metal bearings in primary total hip and hip resurfacing as well as revision surgery. I have revised 2 for adverse wear 7 years after implantation. I know that most other high volume hip resurfacing surgeons have a similar experience. The revisions were straightforward and the patient enjoyed the same rapid and complete recovery as if she had a primary hip replacement.

Currently less than 5% of my practice involves revision surgery. However, I have revised over 100 metal plastic replacements for excess wear. Furthermore significant wear related damage to the tissues is seen in virtually all metal plastic hip replacement or knee replacement revised for other causes.

A surgical group that has seen a surprisingly large number of wear‐related failures of metal bearing implants has coined the term "pseudotumor" when an inflammatory soft tissue mass is seen around the hip of a metal bearing implant. However, this inflammatory soft tissue reaction to metal wear debris is not much different than the inflammatory reaction that we have seen with plastic wear debris for many years.

All artificial bearing implants give off wear particles. The question is, which type of wear debris is best tolerated by the body? During the last 20 years of joint replacement polyethylene osteolysis (bone destruction caused by plastic wear debris) has been a major problem. But anyone who has revised total joints is also aware that polyethelene debris also is always associated with large amounts of soft tissue reaction around the joint. Polyethelene has been improved, and metal bearings have been developed. Both give off much less wear debris than the old polyethelene implants. The question is which results in less wear related damage? At this point we do not yet have the answer. Adverse wear reaction is a serious problem, but fortunately it is very rare.

Lets put this into perspective. The most common reason resulting in revision of total hip replacements in the US is hip instability (recurrent dislocation). 20% of all hip revisions are done for this reason. This is far more common than adverse wear reaction. Hip instability is a very disabling condition that occurs in 3‐5 % of hip replacements. The rate of instability for large head metal bearings is less than 1/2 %. Larger bearings are the solution for this problem. Large head metal bearings (resurfacing and total hip) are currently the only ones that allow reconstructing the hip in a biomechanically normal fashion to avoid instability. Proponents of plastic and ceramic bearings realize this and have made their bearings thinner recently to allow larger heads to be inserted (32‐36mm). This has made them more stable, but 32‐36mm does not yet approximate normal femoral head sizes in the average female (48mm) and average male (52mm) patients. These larger head (32‐36mm) implants for plastic and ceramic bearings have only been in use for a few years and it is not yet clear if these bearings will break at a higher rate because they are thinner. I would not recommend impact sports on thin plastic and ceramic bearings. Anatomic sizing that matches the patient's own size is only possible with large metal head designs. These are stable and can tolerate repetitive full impact without breaking. Wear rates are not significantly increased by running.

In the last few years we have learned that these rare cases of adverse wear in metal bearings are related to three factors: steep acetabular inclination greater than 55 degrees, small component sizes, certain component designs with an extremely shallow arc of coverage. At this point it is still only a very tiny percentage of patients with cup inclination angles above 55 degrees that have had wear problems. If a patient with an inclination angle above 55 degrees develops symptoms years after surgery, I would first check metal levels and an MRI. If the levels were high or a soft tissue mass developed I would recommend revision. So far this has happened twice in my practice.

More important, however, is prevention of this adverse wear complication. Since this information about cup inclination has become available several years ago we developed and tested a protocol for measuring the inclination by XR during the operation. The paper reporting this technique will be published in CORR this year. Using this technique in every case, I now have had no cups implanted with inclination greater than 55 degrees since 10/ 2007. We expect that this technique will completely eliminate this rare cause of failure in metal bearing hip implants: adverse wear reaction.

Knowing the cause of resurfacing failure can ensure successful conversion to THR by Edwin Su, MD
The shell can be retained in cases involving femoral neck fracture, femoral loosening or impingement.

Read Complete Article by clicking here

March 2010

Causes of failure

"The cause of failure must be carefully assessed prior to the conversion surgery in order to ensure an optimal THR outcome," Su said. He noted that femoral neck fracture is the primary cause of short-term failure in resurfacing procedures. He theorized that the rate of these fractures could be reduced with improved surgical techniques, careful patient selection and preoperative evaluation of bone quality. Inadequate acetabular fixation or the so-called "slipped cup" is another cause of early failure, which may also be related to surgical technique.

"The greatest cause of a mid-term failure is femoral component loosening and osteonecrosis probably plays a role in this," Su said. "I think that component malposition is going to play a large role in these mid-term failures as well." He noted that mid-term investigations of patients with acetabular component malpositioning revealed painful metal reactivity requiring revision.

Other causes of failure include metal hypersensitivity and unexplained pain due to impingement, undetected stress fractures or pseudotumors...

...Shell retention or full revision?

In planning conversion procedures, surgeons have the option of retaining the shell from the hip resurfacing.

"I think this is acceptable for a well-positioned, well-fixed and undamaged shell," Su said. "It is applicable in situations such as, a femoral neck fracture and in a femoral loosening...

..."A full revision is necessary when there is component malposition of chronic duration because there will be damage to the metal components," Su said. "It is also best when there is a question of metal hypersensitivity."

Reference:

• Su E. Surface replacement conversion: Assuring an optimal THR outcome. Paper #44. Presented at the 26th Annual Current Concepts in Joint Replacement Winter Meeting. Dec. 9-12, 2009. Orlando, Fla.
• Edwin P. Su, MD, can be reached at Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021; 212-606-1128;

WHAT ABOUT NAVIGATION

Today navigation is still a tool that is not easy to use and that needs a certain learning curve as resurfacing itself also has.

So it is not a useful tool today for resurfacing beginners, where it should be! It would be nice if it would be a help at the start of the learning curve.

So can somebody with experience use it or should they use it?

It is like doing a certain approach and having experience with it, so it feels better and confident.

Most of the experienced surgeons do feel they do not need it. MAYBE it could help.

BUT there are some things that have to be cleared out still today:

*there is no correlation in most of the systems between head and cup.
*Most of the systems only look to the head, and nobody can tell us today what is now the best place to put the implant
*It would be the best to use it for the cup because there we have the most failures!

BUT AGAIN the most problems will be with females, that easily have twisted pelvis on the table and smaller sizes, and it is not sure it will have a big influence here.

If it is a system with preop CT of the pelvis to do the acetabulum, the pictures are taken in SUPINE (lying down position!). The patients walk and run on their hips, they do not lie on them, and that can make a complete difference!

So we are not there yet, if something could help me to do better surgery it would be navigation, but as it is today, it is not a 100% proven project. I have today so designed instruments that I call it navigation without navigation; of course in other sites navigation really could help!

I do not know if the 7 malpositioned cups in my series of 3000 would have benefited with navigation, possibly yes, but maybe would have had others where then the placement was worse?

It is the future?, maybe, but not there yet at present for everybody. That is why not everybody is using it, not just because we would be to lazy, to old, to stubborn or whatever.

If it would be used tomorrow in all cases from the start, the worry is also there, that if the navigation fails we do not know anymore what to do. All these facts should not be used for marketing or publicity issues but left to the orthopaedic community to make it better, try it and try to succeed better, what prof.Cobb, myself and all others I think try to do.

KOEN

koen de smet

hipsurgeon amc gent krijgslaan 181 9000 GENT BELGIUM +3292525903 www.heup.be

anca clinic roma valle giulia ROMA ITALY www.ancaclinic.it

There is some data indicating that navigation can improve the accuracy of femoral component placement in hip resurfacing.  The real issue is "compared to what?"  For an inexperienced surgeon, navigation may help him avoid component positioning problems that have been associated with "the learning curve".  However, for an experienced surgeon, who has an established mechanical alignment system with a high success rate - it is difficult to demonstrate an advantage to him with a navigation system.  Further, the registration process takes a little time – so the cost-to-benefit ratio for the experienced surgeon in a busy O.R. is questionable.  The navigation systems are not hard to learn to use, even for old guys like me!

A bigger challenge is acetabular component positioning.  This is true for total hips, and even more important for resurfacing.  There are 2 parts to the acetabular positioning problem.  The first is identifying the desired position for that patient and the second is putting the cup in that position.  Keeping the pelvis in one position and finding accurate pelvic/acetabular landmarks can be challenging.  The lateral opening angle is the easier part.  Most surgeons today agree that between 40 and 50 degrees is desirable.  Version is more complicated because the desired acetabular version is dependent on femoral version.  Acceptable version is also related to the lateral opening angle and the resultant bearing contact area.  Again, the issue is experience.

If I have any doubt about component positioning, I get an intra-operative x-ray.  Admittedly, there can be some challenges to getting a good intra-operative view.   For what it’s worth, we did an x-ray review of my first 500 resurfacings (minimum 1 year follow-up).  I have never had a femoral neck fracture and all sockets are below 50 degrees lateral opening.

Best wishes.

Thomas P. Schmalzried, M.D.

Computer aided navigation is an interesting concept. However, there is no evidence that it leads to better clinical outcomes and fewer failures. On the other hand, there is ample evidence that surgeon experience has a dramatic effect on outcomes and complications. 

One way to conceptualize this is that the experienced surgeon’s brain is a computer with much more sophisticated "software" than a navigation computer. When a computer is programmed, an algorithm must be created which has certain inherent limitations. Furthermore additional significant sources of errors are introduced by the registration of anatomic points for the navigation computer in surgery.

My personal opinion is that navigation that is based on a pre-operative CT scan data, which is being pioneered by Justin Cobb, has tremendous promise in the future to improve the results. At this point, we are still in the early development phase. It will probably add several thousand dollars to the cost of each operation. 

In summary, I believe the right kind of navigation surgery based on accurate 3D CT scans holds tremendous promise for the future. It will still require an extensive amount of preliminary development work before it is ready for routine use. 

I hope this helps with this very complex issue. 

Best regards,
Thomas P. Gross, M.D.

Computerized navigation has been around for a long time, in total hips, total knees, and now hip resurfacing. A lot of surgeons, including me, have tried it out and not seen an advantage in all but very exceptional cases. Yet other surgeons use it on every case.
 
This is what I think about computerized navigation: It is a tool which can narrow the "bell-curve" of component position, but the curve still has some spread. That helps a surgeon avoid "outliers", or badly misplaced components. Navigation does not make component position the exact same every time, but it helps avoid those outliers. (If it was the exact same every time there would be no bell-curve at all.)
 
So, if a surgeon has no outliers, in other words if he is doing a good job of keeping his personal bell-curve narrow, there is no advantage to using computer navigation. Alternatively, if a surgeon thinks he might accidentally misalign a component so much that it would be considered an outlier, the computer may prevent that.
 
Like any computer, what comes out depends on what went in. Registering the anatomy (which tells the computer where everything is) at the beginning of a computer-navigated operation is not at all an exact science, but depends upon knowledge and experience. It's the same with mechanical alignment jigs. With either method, one should hope that the surgeon is ready to adjust the verdict of the computer or the jig to place the component accurately in the bones which are clearly visible.
 
Are there any downsides to using a computer? Well, there is the extra time involved, which prolongs the surgery (think infections, blood clots). There is extra expense. There is often one more person in the OR, and more traffic in the OR can lead to infection. There is the possibility of surgical complacency if the doctor believes in the infallibility of computers.
 
I have heard this discussed at resurfacing meetings, and people whom I respect more than any others in this field have tried navigation and declared it "useless", and a "waste of time". While unwilling to go quite that far, it does make me think I am fine in continuing with mechanical jigs.
 
Your question about doctors not having 100% "retention" due to component malposition requires a reply. Personally, I have not had any failures in almost 600 resurfacings due to component malposition. I have 1 femoral neck fracture due to leg presses 8 weeks after surgery, and one pelvis fracture resulting from trauma 2 years after resurfacing. That's it. But malposition is an important cause of fracture, wear-related failure, and possibly pseudotumors as well, so should be avoided.
 
Any surgeon "young" enough to learn hip resurfacing is certainly young enough to learn the much easier task of computer navigation, so people who consider someone too "old" to learn navigation are being silly.
 
Similarly, a patient who would choose his surgeon based upon their use of computer navigation is badly misguided. There are many much more important issues to consider.
 
Having said all this, I wouldn't be surprised if at some point in the future surgical navigation becomes more accurate, easier, cheaper, and quicker. Robots will substitute for doctors. Surgeons will look back on the old days and shake their heads in amazement that we used to do all this by hand.
 
Peter Brooks MD, FRCS(C)
Cleveland Clinic

Using computer navigation in  joint surgery is a double edged weapon. While potentially it can reduce the number of outliers,  it can also cause tremendous deviations and absurd placements which would never be done with conventional jigs. I have seen many examples of this done elsewhere and referred to me for revision surgery.

Generally the input to the computer is made by a technique known as bone morphing where the surgeon uses pointer probes to point out the various bony landmarks to the computer. If the surgeon makes an error in this step then it obviously carries on in all further steps leading to a faulty placement. To argue that it removes human  error is most irrational.

We have the brainlab navigation ( market leader in navigation)  in our unit since 2007 and I did a series of cases at that time ( about 80 cases) . I have to say that the femoral cap placement was inferior to my placement with traditional jigs. However I found it useful when one had distorted anatomy as in previous prox. femoral osteotomy. I still use it for such cases.
 
There are many reasons in my opinion by which the conventional jig is far superior to the navigation in hip resurfacing.
 
1. bone morphing with the pointer probes damages the neck capsule which I protect passionately during hip resurfacing surgery and which I am sure is one of the key elements for my success rate.

2. I  use navigation routinely  during my Total knee replacements as the aim of the TKR surgery is to allign the components to the hip and ankle which are not visible in the surgical wound. In contrast in hip surgery the goal is not to align hip component to the spine , pelvis or knee/ ankle. The aim is to align components to local landmarks in the surgical wound, the location of which is given to the computer by the surgeon.  Then the computer gives back the same information which the surgeon offered in the first place. ( this is unlike the TKR where the computer picks up the hip on merely moving the hip and not morphing). Arguments that the computer increases accuracy in hip surgery is frankly absurd and have to be dismissed as marketing techniques.
 
3. The concept of incorporating the  combined anterversion is now the key in operating on FAI ( Femoro- acetabular impingement) which is the pathology in over 95 % of male patients having primary osteoarthritis. This is a dynamic assessment and can be done only with a jig using a lat cortex pin and cannot be done with navigation.
 
Having said all of the above  one must make a distinction between what Prof. Cobb uses and what others use.

Prof . Cobb is the  only one to my knowledge who uses a CT based navigation. The CT gives information which the surgeon cannot access unlike imageless navigation with all other surgeons which depends on surgeon's input based on bone morphing that  defeats the whole purpose of navigation.

In conclusion I would like to say that imageless navigation has very limited role in hip arthroplasty ( eg previosely operated cases) and is an excellent tool in Knee arthroplasty.
CT based navigation for hips which is still not available commercially ( which prof. Cobb uses) may have a significant role in hip arthroplasty. This has to be balanced with the radiation dose for routine CT to be applied universally( approx 30 -50 conventional x-ray dose )
 
wishing you the very best
 
with best regards
vijay bose
chennai

Dr. Barry Tannen (bilateral HR 12/18/08)

I am a 52 year old physician who had bilateral hip resurfacing with Dr. Su on December 18th 2008 at the Hospital for Special Surgery in New York. I had been diagnosed with moderate to severe osteoarthritis 3 years earlier and increasingly had to deal with the pain and limitations that this brought on. I am an avid tennis player who competes locally and in USTA tournaments and obviously my tennis game was greatly impacted, but so were ordinary activities of daily living such as tying shoelaces, etc.

My experience with Dr. Su, his staff, and the entire team at the Hospital for Special Surgery was nothing short of amazing. I left the hospital 6 days after surgery and was discharged to my 2 story home. My wife was terrified that I would be climbing stairs immediately, but it was no problem. I started outpatient physical therapy one week after being home, returned to work 4 weeks after surgery, and started playing doubles tennis in 8 weeks, singles in 12.

I feel better than I have in at least 8 years, maybe longer. I enthusiastically recommend HR, and especially Dr. Su who is an amazing surgeon in my opinion.

Emanuel captures tennis tourney

Temple Emanuel captured the recent Jewish Athletic Group (JAG) Tennis Tournament. Barry Tannen (left) and Mike Spivak hoisted their trophy. The duo overcame the father-son team of Richard and David Fischer of Cong. M’kor Shalom in the finals. Over 30 area players representing many area men’s clubs participated in this year’s event.

Hello, I am a 37 year old former (and hopefully again in the future) athlete who recently had my right hip resurfaced with Dr. Gross in Columbia, SC, having traveled from my home in Charleston, WV for the procedure. My story and this information is for those who are scheduled for or may be considering the procedure, I would like to pass along as much information and personal experience as possible for your benefit, as so many others have done on this wonderful website.

Would like to first summarize that so far I am completely satisfied and recommend the procedure 100%. Also, I wholeheartedly recommend Dr. Gross and his wonderful practice.

As of today, Aug 15th, 2009, I am almost to the 5 week mark post-op. From the moment I woke up from the surgery, I have not had any pain in my hip more than what feels like a muscle stretching or general tightness / stiffness. There is no trace of arthritic or bone pain. I'm not sure I had any expectiations either way, as I read lots of stories both ways - people that had problems and those that sailed through. It is hard to believe that there could be no pain, not with all the wrenching around that goes on in there. Dr Gross has videos on his website showing the procedure (ha, I couldn't bring myself to watch them until AFTER the surgery) - your hip is sliced through, dislocated, and then subjected to medieval torture devices and power tools! How can that not hurt later? But, for me, it doesn't.

I have to say, I was feeling very sketchy in the pre-op room where they start to work on you. Needles and pills everywhere, people coming and going, doing weird things to me. And then, wheeled into the operating room. Just like on TV, with everybody in masks, and the overhead light the size of one of those old satellite dishes. I don't remember much, but even in a sedated mode, it was scary. Then that's it – I was out. I have heard they ask you to count or whatever, but as far as I can remember, they snuck up on me.

The first 24 hours after surgery were the hardest, but even that was not too bad. Even had it been worse, there's not a lot of remembering due to the pain meds and the lingering sedation. I was told Dr. Gross does five surgeries a day, twice a week. Mine was on a Monday, at 9 am. That made me second in line that day. In my mind, that was great - that way he got to wake up and practice on someone else before hacking on me (ha). Seriously, though, I wonder about these things. Doctors are people too, I want them to have their A game when it's me under there. That was really my only question during my one and only office visit – "hey, Doc, you're not going to go out and get wasted the night before my surgery, right?" He said he wouldn't, just for me. Sweet.

Speaking of pain meds, they gave me vicodin that first day and I think I took my prescription two or two and a half more days after that. As I said, there never was any real pain from the surgery, but they kept saying "stay on top of the pain, if you get behind, it's harder to catch up". Well, at that time, I didn't know if some big pain wave was coming or not, so I took the meds. I really don't think I needed it. Hard to tell. The only thing that hurt was when they took the catheter out on the day after surgery. That was bad. Sort of like a vacuum cleaner hose had been up there all along, and got removed along with the catheter hose. There was this weird suction feeling along with the discomfort.

A physical therapist (PT) came and helped me walk that 1st afternoon of my surgery (a mere few hours after the surgery!). The walk was with crutches, but the crutches were for balance, not to take weight off the hip. I have read that they want you to put weight on the hip to help press-fit the devices into their respective slots. The most difficult part was keeping balance considering the lingering sedation. Mostly, though, I just laid there in the bed. The PT also said to keep moving my feet and legs. She gave some prescribed motions to do.

Providence Northeast Hospital is 1st class. Everyone that I came in contact with there was super. Also the food was not too bad. The hospital is yet part of Dr. Gross's well-established system that is wonderful.

I was told to plan for two nights in the hospital, but it ended up only being one. That first night sucked. The main reason is that it was hard to sleep with the O2 / heart monitor beeping all the time and the nurse coming in every two hours. Also, my heart rate kept going down too low, which would set off an alarm. I don't know what was worse, the alarm, or me wondering how bad it is to have a heartbeat low enough to set off the alarm. The low heartbeat was surmised to be me being in relatively good cardiovascular shape, along with lingering sedation effects. I still hardly slept at all.

At the consultation appointment prior to surgery, they asked (made?) me to buy this cold pack machine that is basically a little igloo cooler filled with ice water, attached to a pump, some hoses, and a bandage. I mention this because had I known it was going to cost so much out of pocket for the thing, I could have purchased one on eBay, brought it with me, and saved some $$. But I wasn't aware I would need this prior to the surgery and therefore didn't know to ask if I could have brought my own. Anyway, cold water circulates through the bandage. I was told to bring it to the hospital. After the surgery, they kept it on my hip and leg, circulating cold water constantly. When I left the hospital, it was sent with me, and I used it every 2 hours or so, including in the car on the way home. I think that was a big help to my quick recovery, by minimizing the swelling. I have read about people with bad swelling problems; I had none.

The next day, Dr. Gross stopped by my hospital room. He asked a few questions, and advised that I could leave later that day. I was all for that. Also, a PT came by and explained some of the disabled person tools like the sock put-on device, followed by another walk. I was able to stand and take a shower. I got a little dizzy in there, which I believe was due to the heat and lingering sedation and pain meds. Fearing possible fainting, I had to get out and sit on the toilet. Later that afternoon, I was discharged from the hospital. They make you ride a wheel chair out, but I could have definitely crutched out on my own power.

The second night, which was in a hotel, also sucked. The main problem was the whole sleeping on your back thing. The main mode of sleeping the first few nights is on your back with a pillow between your legs. You are allowed to turn over on either side, as long as the pillow stays between your legs. Well obviously, I wasn't going to lie on the operated side, and while lying on the good side, I was not confident in the ability of the operated side/leg to stay under control. That leaves the back-lying position. There's only so long you can stay in one position before muscles get tight, and general discomfort sets in. It was not a good night. In general, the confidence of sleeping on the good side grew, and by 7-10 days, I was in a routine of moving from back sleeping to the good side every 1-3 hours, with good sleep in between. It helped me to sleep in a recliner for a day or two before moving to my regular bed. One other thing that surprised me was that I had to pee every 1-3 hours through out the night. I surmise that it was a side effect of the catheter. That very slowly went away up through the 3 week mark.

Wanted to mention that that 2nd night I had a fever that got up to 101. I was somewhat nervous about that. It's hard to know in the moment if it's just temporary (it was), or if it's going to get worse. Make sure you have a thermometer with you.

On the 3rd day post-op, my wife drove me and our 2 year old daughter on the 6 hour drive back to WV. We have a CR-V, and I sat in the back seat with the front passenger seat reclined all the way back to give my legs room to stretch out. Could definitely have made it sitting in the front, it was just even better back there. The ice pack has a hand pump bulb thing, which I used to keep the cold circulating on my hip and leg. We stopped 2-3 times so I could get out and walk.

My walking progressed roughly as follows:
1->4 days - walking with crutches
5->20 days – walking with a cane or one crutch. Towards the end of that period, walked with a limp when not using the cane.
21 days -> now (34 days). Walking fine with zero assistance. Limp is almost completely gone.

Again, it seems crazy to me to walk, unassisted, with no limp, so soon. Most of the time, I have to keep reminding myself that I recently had hip surgery, lest I do too much too soon and risk damage to it. And really, my belief is that it would be hard to damage it, but I'm sure not going to chance it. Like on the stairs. I could walk up the stairs normally with no problems by 21 days. I catch myself taking two at a time on the way up (including with the operated leg!), like I used to do before the surgery, and have to slow down, since, who knows, that might not be good for it. Definitely one of the best gifts of the procedure is the "not-thinking-about-my-hip" mindset it allows, in contrast to before, where the pain when I walked consumed my attention.

Some background on my situation and events leading up to my resurfacing:

I am a former college basketball player, and have enjoyed continually playing basketball at a fairly high level up until this spring; when my hip pain finally forced me to stop. It began around 5 years ago as an occasional snap or click in there, and gradually progressed through tightness and stiffness to a slight limp in the past 2-3 years (people would ask "why are you limping?", and I didn't even realize I was). Couldn't pinpoint what it was, but last spring I knew something was really wrong. An X-ray showed "severe degenerative changes" (loss of spacing superiorly, osteophytosis), basically arthritis. There's not much positive in those adjectives "severe" and "degenerative". Was pretty crushed by that news.

Began my research on problems of the hip. Purchased a couple of books and eventually found Surface Hippy. Visited a recommended orthopedic surgeon here in Charleston, WV. He diagnosed arthritis caused by congenital (birth defect) hip dysplasia in both hips and recommended a total hip replacement in the really bad one, noting that the other one will require one in the future. There's another 30-something-year-old guy in my office with one of those and he's not allowed to run on it. I mentioned hip resurfacing to this surgeon and he noted that he didn't recommend it due to risk of femoral fracture and un-proven track record. OK, well, I have to think about this.

Was able to play basketball this past winter. Would basically take my daily Celebrex and supplement it with two ibuprofen before going out to play. By March, people were feeling sorry for me and saying I should stop. I would limp-run up and down the court. The weird thing was though, is that when I quit for good in April, it REALLY got bad. It went from a manageable limp in April to a "I can barely walk 2 blocks" severe limp by May. It was like the running and exercise had been keeping it loose. Got a cane; it was the only way I could get from my cubicle to the bathroom. Weirdly, though, I could still play golf. Would ride the cart up to my ball, cane my way the rest of the way, and then hit the ball. Lost 2-3 clubs worth of distance (due to not being able to push off with my right hip), but oddly, it didn't hurt my scoring. I theorize that I was now playing old man golf, where it's hard to lose any balls if you can't hit it far enough to get into trouble, ha!

Meanwhile, the more I researched re-surfacing, the more it was crystal-clear obvious that it was the thing for me. Active, young, good-looking (oh, well, 2 out of 3 ain't bad). It seems utterly ridiculous to cut off the top of your femur when there are other alternatives. There are so many other benefits, but if you're reading this, you're probably already educated as to those, so no wasting time re-preaching. How could I find out if there were any few orthopedic surgeons in this area that would do resurfacing? Call each and ask? I don't know, I guess I could have done that. Found one that was on the Birmingham Hip website and visited him. He had only done 8 procedures. I believe it is important to have someone with lots of experience at this. That's one thing that is so incredibly helpful about Surfacehippy - the doctor experience data. I cross referenced my insurance coverage with doctors that had significant experience (at least 100 procedures) within a 2 state radius and that gave me a manageable list to choose from. Ended up going for the high end of experience, which was Dr. Gross, and believe that was the very best choice I could have made. Will not hesitate to return to him when my other hip gives out. Definitely hope it is later rather than sooner, but I now have no fear what-so-ever about the procedure.

Wanted to also share some information about the financial end of things. Below is what I have experienced so far. I have Aetna Open Access (EPO) insurance.

1. At the doctor's office prior to my surgery, they suggested I buy the below items, but I am unsure whether I could have refused at the time:
a. Crutches (insurance doesn't pay for all of it) ~$15 copay with my insurance (you can bring your own if you have them, eliminating the need to purchase in the office)
b. Disabled person care package (grabber thing, long shoe horn, sock putter-on thing, and long sponge on a stick) $60
c. Polar ice pack. Mine was a Polar Care 300 model manufacturered by the Breg Company. It was $250 in the doctor's office. The reason I list it here is that these are on sale on Ebay for $70-$100. I would have bought mine there if I would have known.

2. Dr. Gross's office requires a pre-payment of $1,200 which is for having a Nurse Practitioner present during the surgery; they said most insurance companies wouldn't cover that. I paid that, and am still not sure if my insurance will cover that or not. There is also a prepayment of $1,000 for some people, if their insurance won't cover "minimally invasive technique". I did not have to pay that one.

3. So far, my insurance website says they've been billed a little over $51K. Thank goodness for insurance, right?! That is definitely a lot of money, but to me, it would have been worth paying whatever.

In closing, I am less psyched about getting back on the basketball court than I was before the surgery. It may have something to do with the thrill of just walking painfree being plenty of satisfying exercise at the moment; also it's summertime and golf season. Speaking of golf, I got the OK from Dr Gross's office to return to the links at about the 5 week mark, so that will keep me busy until winter. Knowing myself I'll be back on that court, though. Sweet!

That's all I have as of now, best of luck to you with your decision, and your surgery. You are on the right path!

I was not able to find anyone in Atlanta with a good track record doing resurfacings -- so a very big "Thank You" to SurfaceHippy.info and the fellow surface hippies on this site. 

I started having unbearable pain around November of 2008. I called Dr. Gross's office in December after speaking with Mike from this site who had a bilateral with Dr. Gross back in June. When I hung up with Mike I called Dr. Gross's office and on the first call had tentatively scheduled the surgery dates pending me getting the package together.

I got the package put together according to the protocol on Dr. Gross's website and Dr. Gross called me to confirm I was a candidate. I drove to Columbia from Atlanta on a Friday for my pre-op consultation and met with Lee Webb and Dr. Gross (about 3-3.5hr drive). I drove back to Columbia the following Sunday (Super Bowl Sunday '09) and got to the Courtyard Marriott in time to watch the game and get a good nights rest before Monday's surgery.

Monday was very smooth at Providence NE. I went in a bit early and was in pre-op in no time. The whole pre-op team was a lot of fun, the anesthesia team, the nurses... it was a positive environment. The surgery was the blink-of-an-eye kind of thing where I felt like I closed my eyes for a moment and then I am coming to in post-op with the post-op nurses.... to whom I am sure I probably owe an apology for some reason... and then after a while I am being wheeled up to the room for recovery. I was late in the day so the following morning the Physical Therapy team had me doing the exercises, and walking the hall for the first time on crutches. Then the Occupational Therapist showed me how to use the ADL (aid to daily living) kit. Those OT/PT folks were a lot of fun and very helpful to get me started on the way to recovery. The floor nurses were very helpful and good people, one of whom is a fellow Dr. Gross resurfacer!

Wednesday was basically a repeat of Monday. They wheeled me down to pre-op and started with the prep and again it was a very positive experience with the anesthesia team and the nurses and "vampirella" the vampire lady who loved my veins. Then in what seemed like a few moments I was coming to in post-op -- and probably saying things I shouldn't have been -- and then I was wheeled back up to the room. The PT/OT team had me exercising and up and walking on Thursday and then we did a little group PT session and practiced stairs on crutches and walked the hall a couple of times. I was able to shower on Thursday evening, standing up.

Friday after breakfast I did a little PT and then was discharged by 11am. I rode home to Atlanta and got out a couple of times to walk around a rest stop and stretch a bit.

The one thing I would do differently is wear the provided ice packs on the way home. It was cold the week I was in the hospital and some nights that ice felt pretty cold so I was not to fond of the ice. So I didn't use the ice on the way home.

Well I got very swollen. This is probably the one thing I was not prepared for from doing my research. Dr. Gross told me I would probably swell up and I didn't really know I would swell up so bad. I believe it may be normal, maybe not, but the entire length of my legs were enormously swollen starting on that Friday and increased through Sunday. So Saturday, Sunday and part of Monday I spent with legs elevated by a couple of sofa cushions with the ice packs running, laying on my back (for the most of the time) working to get the swelling down. I called Lee Webb on Sunday and she told me to elevate and ice and that the swelling was probably at its worst on that particular day -- she was right. On Monday (5 days post-op) the swelling had already started to decrease rapidly and I was feeling so much better.

Crutches: I was doing my exercises as prescribed and walking on two crutches until 9 days post-op when I felt like the crutches were holding me back at that point. I had shifted to one crutch at 8 days post op and it was a bit awkward so I decided to get a cane.

Cane: I shifted to a cane 9 days post-op and it felt more natural than the crutches. I was glad to be rid of them.

Ten days post-op: Armed with a cane, I went to the Kiwanis Club's pancake breakfast fundraiser and was amazed how well I could stand up in a very long pancake breakfast line inching around an elementary school cafeteria. I am sure most folks with hip pain can relate -- this would not have been possible pre-surgery. I would have had to sit down every two or three minutes to ease the pain. This is when it clicked with me how well the surgery/recovery was going.

Then I walked around Wal-Mart behind a shopping cart and picked up a couple of items. Then we stopped by Lowe's for a few things and I was able to walk fine with the cane. I just had to take it easy and slow getting in and out of the car so as not to break the rules prescribed by the PT team.

Eleven days post-op: Went to church. Walked in with a cane and everyone was wowed that I had bilateral hip surgery and was walking so well. I have to admit I have been pretty wowed by how well everything has gone -- and I thank God for all of it. And I thank Pat and all the helpful people on the surface hippy website and everyone on Dr. Gross's staff that were so welcoming and hospitable, and all of the folks at Providence NE hospital that were part of the process.

Thirteen days post-op: Getting in an out of the car is getting easier. I still have this pain that last about 20 seconds when I stand up after having been seated for a prolonged period of time. I believe this will pass with time and it is so minor compared to the pre-op pain I was having.

I am 34 yrs. old and am in pretty good physical shape. It turns out I had worn a large hole on my right femoral head approximately 3 cubic centimeters. Dr. Gross told me that if I had waited much longer I would have had to go with the THR -- thank God I called in time! He was able to graft the hole and "achieve an excellent press fit."

I hope writing this will help someone else benefit from my experience – since I received so much valuable help from folks on this site. Let me know if I can help with anything.

Thank you,

Tim

Bilateral - Dr. Gross
2-2-09 (R) 2-4-09 (L)
Biomet ReCap/Magnum

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June 12, 2009

Today I am 128 days post-op. I have done so well that I have been quite slack on updating this beloved group where it all started for me. I have no pain whatsoever in the hips. The "clunking" is very few and far between nowadays. I have a 5,000 s.f.+ garden that I have been actively working in every evening without any pain at all. Yesterday I strolled easily up the middle of a long flight of concrete steps to enter a building (without touching the rails)! If that sounds like a miracle to you then you are a surface hippy or a potential surface hippy! I have been back in the gym at a low to moderate level of activity as I wait for the six months to pass. I feel wonderful !!! I could go on and on about the things I can do with ease...

When I read the Wall Street Journal article on last Thursday June 4th, 2009 "Doubts Raised Over New Type of Hip Surgery" by Anne Tergesen, I was a bit disappointed with the negative tone of the article. Naturally, I fall into the "perfect" candidate for the resurfacing being young with strong bones, but I have heard prevailing positive messages from "less-than-perfect" candidates on this site and other places.

I'm sure you know how these things work in word-of-mouth: the old rule of thumb in business is "a bad experience gets talked about 11 times where a good one gets talked about 3 times". I believe it is the same with online reviews and ratings -- many times we only make the effort to put the bad ratings and reviews up so as to help prevent anyone else from having a similar negative experience. With this in mind I believe hip resurfacing's strengths outweigh the weaknesses or we would have a considerably more negative feedback on this site and others.

I felt like the article's title and subtitles set a dominant negative tone and the positives of the article were mediocre in comparison. Oh well... That article is why I said I better log back in and keep folks updated a little better.

Please contact me if you have any questions about the surgery or Dr. Gross or anything else I may be able to help with. In my case it became "no news is great news!!!" over the last few months, but know that I remain happy to help wherever possible! Do not hesitate to contact me!!

Tim