Hip Resurfacing News - Dr. Su

Smith & Nephew Press Conference about the Safety and Effectiveness of BHR

nospam@example.com (Patricia Walter) — Thu, 06 May 2010 21:26:41 -0700

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.

Dr. Barry Tannen Bilateral HR Dr. Su 12/18/08

nospam@example.com (Patricia Walter) — Wed, 17 Mar 2010 10:02:52 -0700

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.

Paul Jacobson Bilateral Dr. Su Dec. 1, 2009

nospam@example.com (Patricia Walter) — Wed, 17 Mar 2010 09:59:22 -0700

I'm 10 days out of bi lateral hip resurfacing with Dr. Su. Can't say enough good things about Dr. Su.

My hips feel strong enough to stand with no issues and no crutches 7 days out. Post surgery, he told me my hips were a mess, and I had pretty big cuts, around 14 inches per leg. I went on a strong natural product regiment right out of surgery, only taking pain killers for a few days, and trying to avoid everything else. I used natural wound healing products and probiotics so my GI system would be normal.

There's no sugar coating the first 7-10 days after surgery. It's hard work and a lot of discomfort, but it's not from pain per se. It's that it's hard to sleep, and you're confined to bed most of the time with both hips having been done. However, with PT, stretching etc, you can recover fast and feel a lot better.

Once you get past the first week, things improve daily. I got my staples out on the 10th day, which is a big improvement. Starting tomorrow I expect even bigger improvements daily, as I'll really begin focusing on regaining flexibility.

HSS is excellent and you can't find a better doctor than Su.

December 27, 2009

I’m 3.5 weeks out of bi lateral surgery with Dr. Su. I’ve been on a stationary bike for a week, no resistance, up to 20 minutes a day, and another 20 minutes walking on a treadmill. I started driving just short of 3 weeks out of surgery, although I get stiff when I’m in the car too long. I’ve had no pain, just discomfort around trying to regain flexibility. I still can’t put socks on (although I got lucky a couple of times), but I’m able to walk without crutches, including stairs. My physical therapist recommended I buy a cane that’s more for hiking, so I got one that collapses made by Leki called the Wanderfreund, and tossed the crutches. I’ve got 2 14 inch scars because my hips were so bad, and yet, I cannot believe how fast I’ve progressed since surgery. The absolute worst time for me was just the discomfort post surgery (not bad pain), and getting the pain meds out of my system (even after stopping all opiods 3 days after surgery), so I could pass the stairs test to leave HSS. Now, it just feels like I have to work hard on flexibility, so I can push the endurance part of rehab. Each day seems to get a little better, and I frankly, I’m surprised at how well things have gone. Still can’t say enough good things about Dr. Su, and for those considering doing both hips at the same time, I’d say the experience has been way better than I expected, and he’s got to be a doctor you consider. In the beginning, the improvement comes every 3-5 days, but as time progresses, I’ve found improvement daily. You wake up and suddenly you can do something you couldn’t do the day before. I fully expect to be back on all non impact sports soon.

Knowing the cause of resurfacing failure can ensure sucessful THR Revision

nospam@example.com (Patricia Walter) — Wed, 03 Mar 2010 11:57:22 -0700

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...

X-ray of a hip resurfacing with a vertical cup position, leading to edge-loading.

Images: Su EP

X-ray of conversion to a total hip replacement with a ceramic-on-ceramic bearing.

Images: Su EP

...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;

Dr. Barry Tannen Bilateral Dr. Su 2008

nospam@example.com (Patricia Walter) — Thu, 21 Jan 2010 15:43:19 -0700

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.

Paul Jacobson Bilateral Dr. Su 2009

nospam@example.com (Patricia Walter) — Thu, 21 Jan 2010 12:31:04 -0700

Mike Bilateral Hip Resurfacing Dr. Su 2009

nospam@example.com (Patricia Walter) — Thu, 21 Jan 2010 12:28:11 -0700

February 14, 2009

I am 16 days post op. I am a 54 y.o. male and had a bi lat hip resurfacing by Dr. Su at the Hospital for Special Surgery in NYC. My staples were removed 7 days post op. I still have steri strips but all other bandages have been removed. There is no noticeable drainage. I began a 3 hr per day outpatient rehab program at Bryn Mawr Rehab beginning 7 days post op. I attended for 6 days. I am now going to rehab 1hr. per day 3 days per week.

At rehab I am doing 20 - 30 minutes on a bicycle at a low level resistance, i.e., L3. I also did standard table exercises, i.e., sitting or supine position leg extensions, glute squeezes, heel slides, sliding one leg abductions, leg lifts ( one leg per time), and seated or supine hamstring stretches, as well as bar exercises. The bar exercises, knee lifts, hip extensions, side raises, toe raises and squats, are done alternating legs after each repetition since they do not want to keep weight on just one leg for any length of time. I also stand b/t the bars so I can put weight on my arms while doing the bar exercises. At first, I tried doing 10 reps per leg on the bar exercises before shifting legs and became sore so I switched to alternating b/t repetitions. The last two days I did the bar exercises with a yellow PT band.

February 15, 2009

I want to thank Vickie, Pat and other bloggers for their support over the past 6 months as I investigated and prepared for my bi lat hip resurfacing. I also want to thank Vicki for assisting me in getting in to see Dr. SU promptly.

My surgery was performed 17 days ago and I am up and about with minimal pain. I take Arthritis Tylenol 1 - 2 times per day and Percocet 1 - 2 times per day. Percocet is limited to bedtime and before rehab, especially long PT sessions.

At my pre surgery consultation Dr. Su recommended I go to a acute rehab facility post hospital discharge b/c I was receiving a bi lat. I fully intended to do so and told the case manager at the Hospital for Special Surgery. My surgery was completed early evening on Thursday night. I stayed in the PACU overnight and until the next afternoon due to a shortage of beds on the med surgery floors. Other than the issues I had with the Post Op Case Managers and PTs which I detail below, the care at HSS was outstanding. The staff is responsive, helpful and caring. The food is very good and the atmosphere is great. How can you complain about a bed by the wall to wall windows overlooking the East River. My only regret is that they would not let me have my nightly glass of red wine.

Dr. Su visited me everyday but Sunday while I was in HSS. On Sunday he called me to see how I was doing. Also one of his staff came to examine me everyday I was in HSS. Dr Su and his staff were very attentive.

I loved the staff at HSS with the exception of the Post Op Case Managers who took over post surgery and the PTs. That said the PTs were knowledgeable about physical therapy they just didn't coordinate with the Post Op Case Managers and didn't advise me regarding what I should do or not do in order to qualify for inpatient acute rehab.

In general the Post Op Case Managers had a negative/pessimistic attitude. They are really Discharge Planners, i.e., primarily concerned with finding a place for you outside the hospital in order to open up beds, rather than Case Managers who proactively help you find the best options post discharge. In addition, the Post Op Case Managers were incompetent b/c they waited until Monday before filing a request for coverage at an acute rehab. This should have been filed on Friday, i.e. asap post surgery as long as you've had at least one PT session. As a result of waiting until Monday to file with the insurance company, BCBS of PA, my request for acute rehab coverage was denied. I appealed 2X and lost both appeals. Note: that approval of acute rehab for bi lat hip patients is usually granted if you don't do something stupid to disqualify yourself.

In this regard, the Physical Therapists were complicit with this mistake b/c they did not tell me what the parameters for acute rehab approval are and encouraged me to try to do things that would disqualify me for acute rehab. For example they let me walk 250 feet with a walker on the 3rd day post op. This apparently disqualified me for acute rehab. Also, as a result I spent 2 extra days at HSS, pending unsuccessful appeals. During this time I was in a catch 22. I got minimal PT and didn't want to do too much less I hurt my case for acute rehab coverage. Meanwhile, by restraining my PT you I risked slowing down my rehab progress.

Advice: Don't do something stupid like this if you are a bi lat. Bi lats should qualify for inpatient acute rehab coverage, single hip patients generally do not qualify for acute rehab, however. In acute rehab you get 3 hrs of rehab a day, w/o paying a co pay for out patient PT. Otherwise, most patients get a PT to come to their home, 2 - 3 times a week for 1 hr/ day. The PT is much less rigorous and complete compared to inpatient acute rehab, so get acute rehab if you can. Make it very clear to the Case Manager that you want to go to acute rehab AND make sure that the Case Manager files for acute rehab approval with your insurance company the first day you get PT. The longer you wait the more likely that your PT progress will disqualify you for acute rehab coverage. IN ADDITION, make it very clear to the PTs that pending approval of you coverage for acute rehab you do not want to do anything that would disqualify you, i.e. walk too far, go up and down steps or succeed at performing ADLs, i.e. activities of daily living.

Luckily, in my search for the best acute rehab ortho programs in the Philadelphia area, I found that Bryn Mawr Rehab had a out patient day ortho program. This program began in August of 2008 and is one of only two such programs in the US designed to treat ortho patients, primarily hip replacements and resurfacings and knee replacements. It provides 3 hrs per day of PT plus nurse supervision, on an outpatient basis. The program is designed to go on for 7 consecutive days. Generally, each patient is examined by a nurse b/t 9 and 10 AM. From 10 AM to 12 PM you get PT. Lunch is provided from 12 PM to 12:30 PM. From 12 :30 PM to 1 PM your rest in a recliner and ice down. You get PT from 1 PM to 2 PM. After 2 PM you ice down and leave. NOTE: this is an outpatient program so under your insurance you may be responsible for a co pay for each visit and the visits are deducted from the number of days of outpatient PT covered by your insurance plan.

IF you can find one of these programs, make sure that they understand that while you as a hip resurfacing patient don't have hip restrictions like hip replacement patients, you do have to prevent prolonged unassisted weight bearing. Stay off the treadmill ( instead use a stationary bike with no or low resistance) and also don't stand on one leg too long. If doing single leg exercises alternate from one leg to another after each rep instead of doing 10 or 20 reps on each leg before alternating.

I am now discharged from the outpatient day ortho program and begin PT for 1 hr per day 3X per week beginning tomorrow. Meanwhile, I am doing about 30 minutes a day on a stationary bike and doing seated or supine upper body resistance training at the gym. I also do standard floor or table exercises, i.e, glute squeezes, bridges, heal slides, abductor slides, leg extensions, and ankle pumps twice a day.

I am looking forward to getting into a pool but I need to be sure that my incisions are fully healed first. I had the staples removed 6 days post op. I only have steri strips remaining. All drainage has stopped. I hope to get clearance in 9 days when I have my first follow up appointment with Dr. Su. I am looking forward to my appointment so I can get clinical feed back re: my progress. I am very pleased with the procedure and my progress to date. I can't wait to be able to resume an active lifestyle.

My pain level has been very manageable. Initially I had some discomfort/tightness in my left hip, need the ball, when I transferred weight for my heal to my toe. That pain is going away. I also have to focus on keeping my left foot and knee turned inward. Otherwise I walk with my toes rotated slightly outward. Sometimes when I walk and keep my toes pointed straight ahead I feel some tightness in the left hip area.

If you are a bi lat resurfacing patient I recommend getting inpatient acute rehab if at all possible. Why? Its a no brainer. If you go to impatient acute rehab you will get 3 hrs per day of PT for 4 to 10 days, instead of 1 hr/ per day, 2 or 3 days per week if you get PT at home. The inpatient acute rehab will maximize your full recovery.

That said unless you have other disabilities, complications or poor at home circumstances, resurfacing patients most often don't qualify for inpatient acute rehab unless they have had bi lat resurfacing. Even if you have bi lat resurfacing you need to be proactive to make sure you qualify for inpatient acute rehab.

My advice is as follows:

Make sure you let your Pre Surgery an Post Surgery Case Manager know that you want to go to inpatient acute rehab.

Make sure your Post Op Case Manager applies to your health insurance company for inpatient acute rehab approval on the same day that you have your first PT session in the hospital if at all possible. You want to show as little progress as possible when you request approval. The insurance company will require submission of all PT notes in making their evaluation. Stay on top of the Post OP Case Manager and make sure they do their jobs properly and promptly!

Also, make sure you let your Physical Therapists know that you very much want to get approval for inpatient acute rehab. Tell them that you do not want to do anything that will potentially disqualify you for the coverage. They should be familiar with the criteria. If they are not insist that they become very familiar with the criteria right away. Do not walk to far, go up or down steps or successfully perform activities of daily living, i.e. get in and out of bed, put on shoes and clothing, climb steps, etc... before your request for approval of inpatient acute rehab is approved. It shouldn't take more than a day or so after the application for approval is filed with the insurance company.

When should you have your surgery??? The timing of your surgery can be problematic. If the application for approval is filed on Friday afternoon or even Friday morning you may not get a ruling until Monday, b/c they insurance company is closed on Sat and Sun. Meanwhile, pending approval you must be VERY CONSERVATIVE WITH YOUR PT AND YOUR IMPROVEMENT. Hence, it would be best to have your surgery scheduled not later in the week than Wednesday afternoon. This way you have your first PT on Thursday and the application can be filed on Thursday afternoon at the latest. If the application for approval is submitted and completed properly and promptly by the Post Op Case Manager and PTs, by Thursday afternoon, you should get a ruling by Friday. That said, if doing it over again I'd rather have surgery on Mon thru Wed. morning if I had my druthers.

IF THAT IS NOT POSSIBLE, Friday afternoon may be the best time for surgery. You may be in the PACU until Sat. afternoon. Your first PT will be Sat afternoon most likely. You can take it VERY EASY during you PT pending submission of your application for approval on Monday morning. If the app is completed properly and submitted Monday morning, you should get a ruling Monday afternoon or Tuesday morning.

Paul Jacobson Bilateral Dr. Su Dec. 1, 2009

nospam@example.com (Patricia Walter) — Wed, 20 Jan 2010 11:28:10 -0700