Jim Hartford, MD, is fellowship trained in replacements and has worked with Dr. Lannin now for about 6 years (PAMC is a big multispeciality clinic with 11 orthopaedists). Now but Dr. Lannin and I do almost all of the replacements).
We became interested in hip resurfacing because we saw a demand for hip replacements in a physiologically young group of patients who wanted to be very active and yet that was the group with the highest failure rates in conventional hip replacement. As metal on metal resurfacing became more successful, we had a group of patients who would seek it out and for a few years, I would sometimes send someone to LA to Dr. Amstutz or Tom Schmalzreid who had studies going on. Also had a friend of mine go to Belgium and come back with two hip resurfacings doing great!
When the BHR got approved, Jim went to Calgary for training and Dr. Lannin went to England and trained with Mr. McMinn. We’ve been doing them now for about 2 years. We did one thing which I think is almost unique in that Dr. Lannin and I decided we would try to do as many of these as we could together. We thought that would be valuable in two ways. One was to increase both our experience simultaneously which we thought would help cut back our learning curve and Two, we thought patients would benefit from having two experienced hip surgeons working together. We’ve really enjoyed that and we think our patients like the idea, too. We have around 120 now but are getting more nowadays because of word of mouth and patients seeking out doctors with experience. It was quite difficult at first, of course, to attract patients as we were very honest about learning curves, etc. and many would shy away, but now we are doing about 12/month and doing pretty well for the most part.
One of us acts as the primary surgeon, with the other assisting. We run two rooms and go room to room so we each have been the primary for about the same number of patients and assisted similarly. We have done a few patients without the other surgeon which is easier now that we have some numbers but we still enjoy the team approach and try to have what we call our BHR day twice/month working together as a team of the two surgeons (and we have two great PA’s, Liza and Rob).
We both use posterior approach. We use a curved incision, so hard to measure length, but probably 6-8 inches. Close with a subcuticular suture so we do not get the “railroad tracks” of staples. We let our patients put weight on as tolerated from the start but with a walker or crutches and then wean to a single crutch or walking stick as soon as they are comfortable. Do follow posterior precautions with no crossing leg in flexion, limit flexion to 90 degrees unless they are abducted at the same time in which case they can go past 90 degrees for 6 weeks. We do not recommend high load such as running for a full year. We base this on maturation of the ingrowth into the cup and statically higher fracture risk if overloaded early though some patients “cheat” and seem to do fine. We have had one femoral neck fracture at 3 weeks post-op, have had one unstable cup requiring revision and one arterial injury requiring vascular surgery repair. No infections, pulmonary embolisms, etc.
We do not age or sex discriminate but go rather on activity and bone quality. Most patients are males under 55 and we do have a tendency to quote Australian registry data. We do believe hip replacement is a good alternative, especially if bone quality is questionable. We do use only the BHR. We do only hybrids – that is cemented femoral components with cementless cups again based on the more favorable data of these constructs (though I still would love to see femoral fixation without cement if a design could be shown to be as excellent as the cemented). We always preserve and repair the capsule if possible.
The ideal candidate in my opinion is an active person with good bone quality with a long life expectancy who wants to maintain a high activity level and wants to preserve bone. Also that they recognize that we do not have all the answers comparing modern total hip to modern resurfacing and that all implants of whatever style have potential advantages and disadvantages.