BHR vs. THR, that is the question

[Dannywayoflife]

Dear Pat many thanks for the great info! Please keep up the great work!! :)

[Vicky]

Hi Kaiser girl,

I know Dr. Klug very well and if you contact me, I can get you on the fast track with him if you like.  I'm a Patient Advocate.

With hip resurfacing, the single most important factor in it, is surgeon selection and Dr. Klug is the only "go to" Kaiser doc for hip resurfacing.  The only follow up you will ever need locally is with your GP doc who can order PT and x-rays which you can email to Dr. Klug for follow up.  I know of patients that have flown to Dr. Klug from even CO.  He really is very good at this. 

Many of us have traveled great distances for our surgeries and never had any problems with follow up care after.  I flew from CA to India for both my surgeries.  You can email me at vicky@ vmarlow.com, just delete the space, and I can get you in touch with Dr. Klug and get you on the fast track if you are interested.  I know a lot of the top hip resurfacing surgeons in the world and we are so fortunate that there happens to be ONE in the Kaiser system.  Feel free to email me and I can also give you my number if you want to call me.

Vicky

[Eitan]

My 2 (more) cents:

Re:  "You will have a much more natural gait with resurfacing and your body will remain much more in balance since no large portion of your femur bone will be sawed off.  Your bone will remain active in it's normal state since it will not be sawed off and have a large, long hold drilled into it."  (From Pat's post)

Um . . . Sorry.  There is no actual proof that the above is true.  This is certainly the theory, but not anywhere near proven.  Mr McMinn, the guy who pretty much revolutionized resurfacing in the '90's (Along with Dr Amstutz, a holdover from the '70's who at age 75 is still going strong in CA, G-d bless him) would have you believe the above, but he's a salesman as well as a surgeon; so you need to take his "dogma" with a grain of salt.  The only worthwhile study comparing resurfacing to THR was done by some guys from Montreal (Vendittolli, Lavigne, and Roy).  They found no difference in any of the 15-20 indexes that they measured.  This includes all gait parameters, leg length, one legged hop, balance, proprioception and on down the line.  In fact, both the resurfaced patients and THR patients for the most part all returned to pretty vigorous physical activities.

The statistical reality (I know.  "There are lies, damn lies, and statistics."  But anyway.) is that, barring major complications such as dislocation, infection, component mal-placement, fracture etc) you have over a 98% chance of being very happy with your result whether you have a Resurf or a THR.  There is no CURRENT proof that a resurf will outlast a THR.  With the new THR technology, (ie better bearings such as Large head metal on metal, ceramic on ceramic, etc) you will likely NOT ever require a revision.   I do not know what your desired future level of activity is, but you probably can reach your goals with either surgery.  Reasons not to get a Resurf have to do with technical aspects such as a small femoral head or neck (found more commonly in women than men), osteoporosis (again, more common in women), severe head or neck deformity etc.  Only a qualified surgeon can tell you if you fall into these categories.

I got a resurf because I wanted to get back to wrestling and submission grappling, very demanding sports which require one to shoot the legs forward and back quite quickly and violently.  I felt that I was probably at higher risk for dislocation if I had gotten a THR.  I was comfortable with my surgeon, who has probably done more resurfs than anyone in Canada.  (I am doing well so far, but certainly not yet back to those sports). Were I not so active, maybe I might have gone for a THR.

In summary, there are some people on this site who have an almost religious revulsion towards getting their femoral head cut off (insert inappropriate joke here).  This revulsion isn't based on any current rational, scientific evidence, but rather on (so far) unproven theories.  Do your homework, choose the best option/surgeon for you, and I am sure that you will do well.  Best of luck.

Eitan   
 

[Lopsided]

In summary, there are some people on this site who have an almost religious revulsion towards getting their femoral head cut off. This revulsion isn't based on any current rational, scientific evidence, but rather on (so far) unproven theories.

No Eitan, the objection to getting your leg bone amputated is based on common sense.

[Vicky]

I agree with the last poster, IF a patient is a perfect candidate for resurfacing after several top hip surgeons (that do many of both have determined them to be so), there is just NO logical reason to chop off a perfectly healthy huge chunk of bone for no good reason.  Of course if they do not qualify after getting the top surgeons to give them a truly unbiased opinion, then a THR is a great option to get someone out of pain, IF and only if they actually really do not qualify for resurfacing. 

Preserving bone just makes logical sense.  Each time you might need a revision, they have to remove more and more bone, why not start off with the least bone removal and the most natural hip.  There is just nothing natural about going down the bone marrow and it can cause some unknown issues with fatty deposits releasing into the blood stream.  This was brought up at the conference by Derek McMinn in AZ recently and Mark Bloomfield actually wrote about it in a post on the UK board a while ago, but it sounds pretty scary to me.

Then there is no getting around the stress shielding once you place a stem down the thigh, no matter how small the stem is, a THR is a THR is a THR.  Also no foreign device is going to have zero problems.  Did you know that the very first pseudo tumor EVER was found in a patient who had a Metal Poly THR device?  Ceramic on ceramic has it's issues as does any other material. 

AND the "NEWER" THR devices have NO history, no data to know whether or not they will last or not.  Many studies that have been done are usually comparing the two after only ONE year, I would love to see a LONG term study done comparing the two.  I know that there has been one on the BHR after 10 years showing that high impact does not at all effect the survival rate.  Who knows with these newer THR devices if someone decides to do heavy impact where they will be at 10 years out because all of these NEWER THR devices haven't even been around yet for 10 years. With the stress shielding and not loading like a normal hip, you risk the stem loosening.  It is all speculation on the docs parts on ALL of these NEW THR devices, seriously, ALL of them have less data than the BHR.

To me, and that is just me, the less invasive BHR and (removing a LOT less bone) sounds a LOT less invasive to me than a THR, and a resurfacing with a PROVEN device makes absolute sense, it is just logical, again, just my oinion.  Doctors have great arguments that sound convincing, but keep in mind that THR's are a lot easier for them to perform, a resurfacing is a very technically demanding procedure that takes a lot of skill and practice and training.  Many surgeons have no interest in learning it and going through the proven learning curve.

For anyone young and active with healthy bone, it just makes logical sense.  I am the perfect poster child for what NOT to resurface!  I am female, slightly hypermobile, have mild dysplasia, extremely tiny bones, my size is 42/48 and have extreme allergy to metal earrings.  I have had my first left hip for almost 5 1/2 years, NO problems and even went back for my right hip just 5 months ago and this recovery has been nothing short of amazing.

Yes a THR is a great option IF and only if a patient does not qualify for resurfacing.  But if they do, why would anyone want so much healthy bone removed for absolutely no good reason?  Just my .02 cents for what it's worth. 

Vicky

[B.I.L.L.]

Kaiser girl. Kaiser put my cup in at a about 65 degrees, (too steep) If I could go back in time I would go to Dr. Klug in a heartbeat. You obviously have to use Kaiser,  why not go with the most experienced resurfacing guy Kaiser has ? No brainer from my point of view, and don't worry about stepping on another doctors ego, so what. (Just my $.02 8))
Vicky put me in contact with Dr. Klug after having no luck through the kaiser channels. Nor cal kaiser and So cal kaiser are two seperate entities that do not communicate well (if at all). Dr Klug looked at my x-rays and spent about 45 minutes on the phone going over all my options, he seemed to care more than the whole staff who did mine, and I never even met the guy ;D. If you gotta use kaiser I' d go see him. Best of luck to you 8)

(Thanks again Vicky !)

[bothdone]

For me, back in 2004, I took the decision to go for BHR.    My main arguments were that it preserves more of the bone and can be revised to a THR later if needed.

As has been posted earlier, who know how long the different systems will last, particularly in different individuals.   You make your choice and go with it.    I have no regrets with my two BHRs.   

Ed

[gary2010]

Hi, I wasted 2 years of my life before I encountered this site and Vicky's, I was advised to wait 10 years and have a THR. I actually considered taking up wheelchair racing!

9 months post op I am running again and well on my way back to full fitness.

[Kaiser Girl]

Hi guys,

I have received a lot more feedback since my last post.  First of all, thanks to Vicky, I am now in contact with Dr. Klug.  Clearly, he's the Go To Guy at Kaiser.  He very kindly offered to be my surgeon and I am seriously contemplating this.  However, I still can't make up my mind... I've sent my x-rays abroad to 4 orthos in Switzerland and 2 in Spain (via family friends); without any financial incentive, they all say do a THR.  Mostly because now with MOM THR they are thinking that it might last a lifetime.  Of course, there is no longterm data on this and I'm not waiting any longer to find out.  BUT, I'd love not to have to ever have a revision.  It's hard to say what my hip and the state of the art will look like in 20 years, but I do have a history of osteoporosis in my family.  So some docs are saying that removing the femur removes the risk of a femoral fracture in the future (obviously).  Why not go THR now and not do BHR now so I can have THR later?  Just a thought.  I'm totally confused and open to more suggestions.  Thanks for all your support.

[Lopsided]

I've sent my x-rays abroad to 4 orthos in Switzerland and 2 in Spain

If you are contemplating Europe, why don't you try Dr. De Smet in Belgium?

[katekosar]

~~ Why not go THR now and not do BHR now so I can have THR later?  Just a thought.  ~~

Not to raise the ultimate boogeyman, but what if your THR needs revision later?  Not a whole heck of a lot left to work with at that point.  For myself, part of choosing BHR is the conviction that I'd much rather have a far less intrusive revision later, if need be.

Just a little food for thought.

kate 

[gary2010]

You can't run on a THR you know

[Lopsided]

Kaiser Girl, have you noticed that:

• There are many surgeons not skilled enough to do the operation that advise against it.
• There are many resurfaced hippies that are back up to full fitness.

You could get a THR if you are willing:

• to get your leg bone cut off,
• your marrow drilled out,
• fragile plastic inserted,
• never cross your legs, sit on the floor or run,
• never play with your children,
• definitely need revision surgery and preferably enjoy it,
• to get second best.

Your decision.

[Kaiser Girl]

I wish I could go to Europe, but I have Kaiser and have to stick with that.  I was just polling for advice.

Of course, they're going to recommend THA if they cant do BHR, but I assumed if I'm just asking their opinion and they're not doing the surgery, they could give me a less biased answer.

And no, I did not know I could not run on THR.  Not that I've ever been a runner, but a quick sprint across the street to chase the dog so he doesn't get run over is sometimes necessary.

OK, Lopsided, you are freaking me out.  I have to look into this more.

[einreb]

Can't run on a THR

I've seen very few references to folks with THR's returning to running.  I know its been done, but it certainly isn't advertised like it is with a resurf.  It used to be a huge no-no with the old small ball poly.  The plastic would eat away at the bone in the femur.

Can't cross your legs??

That applies to the old school small ball metal poly.  Modern larger head ceramic and MOM don't have this problem.  I ve even seen it argued that the large ball MOM THR is less prone to dislocation than a resurf due to the surgical technique, but i suspect its a non-issue done correctly either way.

Can't play with your kids??

I don't get that comment either.  However, I have kids 4 and 6.  i feel that a resurface with the potential to a revision to a thr gives me the best shot of being active with them and someday grand kids. 

I think I hear from the OP that the argument for the THR is that it doesn't have possible the neck fracture issue of the resurface.  I personally would argue that this is HEAVILY outweighed by the fact that a revision from a resurface to THR is much easier than a revision from a THR to a second THR.  They may have to break it out of your femur and use a special larger rod.

I just went through the resurface.  Its fresh in my mind.  I feel I made the right choice even though I was told by one 'top resurfacing doc' that i should get a THR.  Bone preservation was absolutely essential to me.

[Lopsided]

Oh:  And let's stop with the "it just makes common sense" stuff as it really isn't helpful.

Well what is wrong with common sense? It seems like a good way to go through life.

[Tin Soldier]

Anyone out there ever cut a cow femur near the top and looked at the "grain" of the bone in that area and then cut through the ball of the femur and compared the "grain"?  I haven't, but I think it would be a really good way to present the notion that the femur (below the greater trochanter) is not designed to take lateral strain.  It would be similar to drilling out the inside of a branch from a tree, put a steel rod in the hole (a few inches in) and then tried to bend the whole unit.  I suspect the "grain" is linear in that area.  It's not designed to take a lot of lateral strain.  Seems to me a metal shank, with a moment arm (the thinner angled femur top) would want to push outward at the bottom and sort of pry it's way out of the femur.  I think that's why surgeons don't want you putting a lot of impact or excessive weight on a THR. Evolution designed the top of our femurs to have the angle for a reason and with it, the type of bone in that zone, also for a reason. 

That might not sound all that common sensy, but it makes sense to me, that's the main reason I went with HR.  Also, I know some folks with THR and they are pretty strict about not running, not even for a short jog.   

[Kaiser Girl]

Thank you, All.  Objective and factual is what I'm looking for.  I do also have to consider frame of reference when I look at the videos/posts/articles/research.  That's what gets my head spinning, though.  What I don't understand, Pat, is why do some doctors who have no vested interest in my choice, look at my x-rays and say THR?  I want everyone to unanimously say HR!

Actually, Eitan, I must have mis-portrayed myself.  On the UCLA activity rating score, I'm proud to be an 8 out of 10: biking, hiking, swimming, dancing, camping, working out, etc.  And I appreciate your opinion re THRs even though you had a HR yourself.  Not to invite more controversy, but do you wish you had THR instead?  Why did you choose HR?

And einreb, it's certainly a fact that revision from an HR to THR is way better than THR to THR.  But what I'm being told is that the MOM THRs might just last...  Why not get the correct surgery now and never need a revision?  Am I too Polly-Anna on this one?

[John C]

Hi Tin Soldier,
I think that your analysis is pretty strong. As an example, my mother had her first THR by the time she was 70. By the time she was 77, she was on her second revision (total of three THRs). By the time she was 82, the tip of the stem had worn its way through the outside of the femur, causing pain. They told her that there was little hope of her having a successful third revision, so she went from playing golf regularly, to ending up in a wheel chair. I realize that the materials in THRs have come a long way since then, but the outward load of the tip of the stem against the wall of the femur continues to not be an anatomically sound solution. As an interesting side note, the surgeon that did her last revision was one of the top joint replacement specialists in Seattle. His own knees have been so bad for the past ten years, that he has given up most of his sports. He has scheduled TKRs a couple of times, but has always canceled out. I guess he just saw too many bad outcomes.
I did have a friend recently who had a THR using a carbon fiber shaft that is designed to have the same flex characteristics as femoral bone, but other surgeons that I have talked to consider this to be too experimental, citing possible problems with the carbon fiber fatiguing and breaking down.
Looking at my mothers X-rays as the tip of the implant wore its way out through the femur, is one reason that I went with HR.

[halfdone]

Hi KG. Whatever decision you come to, I hope it is something you will feel good about and that the surgery will "give you your life back".  I really have little to add to the robust debate, but if you have not done so already, I suggest that you read the Australian Orthopedic Association report which, as I understand it, is one of the best data analyses of hip prosthesis performance from the national registries, and it may help you settle on the decision.  While some care needs to be taken in interpreting the data (eg sample selection bias, omitted variable bias etc., ie the group of patients with THRs was different from the group choosing HRs, and so on) the data is very interesting.  For what it's worth, I take away great encouragement from the data for HR patients: the performance over time of HRs seems to me to have been remarkably good as compared to THRs considering that during the period of the data (the last decade) HRs were very new, surgeons were "learning" about the surgery (which is more difficult than THR) and optimal placement of the prosthesis, and the patients choosing HRs are the very active ones who are likely to place the greatest demands on the prostheses.  Now we have a good cadre of experienced surgeons, much more knowledge about optimal placement and best surgical technique, and so on, the performance of HRs in the next decade is likely to be even better. 

I know it is difficult to sort through the blizzard of information and opinion, some "expert", some really expert, and much personal perspective.  I respect the care that you are taking with the decision and recognize that as a female candidate you have considerations beyond those of us large boned males.  Good luck and best wishes.  (PS If I was betting on which would last longer, placed by an expert surgeon, between HR and MOM THR, I would bet on the HR - but then I already have  :) :) )

Disclaimer: all submitted as very humble non-expert personal opinion - so no flame wars please!