Enlighten me with your knowledge please

[strost]

Hi - I have done a fair amount of research since 2009 on hip replacements and resurfacing. However, I know I've only scratched the surface. Figure everyone on this site probably did extensive research prior to making their move, so I'm hoping your insights help get more laser focused.

I was scheduled for a hip resurfacing with Dr Gross last July. I was able to cancel my surgery after I found something that eliminated that constant dull ache in my hip as well as other parts of my body (that kept me awake at night and dreading repositioning). I've still been pain free and active, however, I'm coming to terms that I need to get this hip fixed to help preserve my other hip, my muscle strength (since I can't work it in a full range of motion), and my low back and knees which have to deal with the lack of motion. Figure it is better to do it now at 47 1/2 instead of continuing to decline and doing it in 5 years. My xray continues to look worse - bone on bone, sclerosis, spurs, thickening of femoral head, etc. My PT said if 10,000 people showed him the same xray, all but 5 would already have done the surgery and the other 5 have CHF and can't have it! Severe is what the doctors have been telling me. However, they also say if I'm not in pain, then I should wait.

Here are some questions and concerns I have:

1. Component composition: With all the scary news about metal on metal ions, I'm nervous about putting a Biomet resurfacing device in my body. I know problems are normally with the surgical placement which is why I'm willing to travel to see Dr Gross. I also don't want anything in my body that can conduct electricity or ambient radiation.

The other component I'm considering for an anterior approach total hip is a Medacta titanium alloy - niobium, high nitrogen stainless steel, ceramic head and polyethylene. Thoughts or info?

2. Approach: I visited a local surgeon who has a special table to do an anterior approach for a total hip replacement. There are no muscles or tendons cut. He used to do resurfacing and now prefers this approach even for his younger patients. I do like the thought of not cutting muscles like in the posterior approach. Thoughts or info?

3. Resurfacing versus total hip: The main reason I liked resurfacing was it was bone preserving. In a total hip, what normally needs replaced in a revision? Obviously at my age, I will be looking at 2 surgeries. The anterior approach has similar benefits with no restrictions, faster recovery and still able to do lots of sports. Thoughts?

4. Are there any very experienced hip resurfacing surgeons who do an anterior approach and use a non metal on metal component?

Anything else I need to know or consider?

Thanks!
Susan

[Baby Barista]

At 37, I considered many of these points... I'll give you my thoughts.

1) If you look, you'll find just as much scary stuff about polyethylene. Your body can not process or excrete it. It will always be there. At least with metal your body can excrete it. Sure, there have been people who've had nasty reactions to metal prosthesis... but there are people who *die* everyday in hospitals from reactions to asperin. I personally have not seen a documented case of a person succumbing to metallosis.

2) From what I've read, there can be every bit as much trauma to tissue with anterior. It may not be *cutting trauma, but trauma nonetheless from the extreme forces to the tissues when trying to reach the joint.

3) The two orthopedists I saw, before meeting my HR surgeon, told me that current revisions for THR were split between worn poly cups... and loosened femoral stems. Fixing the stem can require breaking apart the upper section of femoral bone, when reassembling with a new stem, screws and wire.

4) A few ladies on this board can tell you about Dr. Pritchett's use of a BHR femoral prosthesis with a Stryker poly cup.

Future studies may prove me wrong on all points. But I know this for a fact: I may be here another 50 years or another 5... however long, I'd rather not spend them in pain. Good luck with everything.

[obxpelican]

Metal Ion issues are usually only when your doctor implants your device at an incorrect angle.  Dr. Gross has a VERY low failure rate due to high metal ions.  All devices have their negatives, ceramics have been known to crack, the plastic types have been known to break down and cause tissue damage.  Right now MOM seems to be the best thing going, that is unless your device is not at a nominal angle.

With some Anterior approaches you can end up with a permanent limp.  The posterior approach is by far th most popular approach today, for good reason.  Also, most all doctors who use the posterior approach preserve the neck capsule.  It's really a non issue.   @ 8 weeks I was golfing, I walked unaided @ 13 days post-op.   I drove myself home for 4 or 5 hours the Saturday following my surgery. 

It's VERY difficult to find a better doctor or facility than Dr. Gross.  Very few doctors have the success rates that Dr. Gross has.

My only regret is that I did not get my surgery sooner.

Chuck

Here are some questions and concerns I have:

1. Component composition: With all the scary news about metal on metal ions, I'm nervous about putting a Biomet resurfacing device in my body. I know problems are normally with the surgical placement which is why I'm willing to travel to see Dr Gross. I also don't want anything in my body that can conduct electricity or ambient radiation.

The other component I'm considering for an anterior approach total hip is a Medacta titanium alloy - niobium, high nitrogen stainless steel, ceramic head and polyethylene. Thoughts or info?

2. Approach: I visited a local surgeon who has a special table to do an anterior approach for a total hip replacement. There are no muscles or tendons cut. He used to do resurfacing and now prefers this approach even for his younger patients. I do like the thought of not cutting muscles like in the posterior approach. Thoughts or info?

3. Resurfacing versus total hip: The main reason I liked resurfacing was it was bone preserving. In a total hip, what normally needs replaced in a revision? Obviously at my age, I will be looking at 2 surgeries. The anterior approach has similar benefits with no restrictions, faster recovery and still able to do lots of sports. Thoughts?

4. Are there any very experienced hip resurfacing surgeons who do an anterior approach and use a non metal on metal component?

Anything else I need to know or consider?

Thanks!
Susan

[Tin Soldier]

Chuck beat me to it.

Strost - I agree with Barista and and Chuck, I'll add a few things

1.  Blood is a really conductor of electricity, becasue of the salt.  I suspect CoCr alloy is too, and I even think Ti is a heckuva good electrical conductor.  I haven't heard of galvanic reactions with MoM components and I don't think the metallosis is related to any sort of electrial/galvanic type of reaction.   The MoM prosthetics have been given a bad rap from the ASR lawsuit coupled with some bad reporting from Barry at the NY times as well as a host of less-experienced surgeons getting out of the resurfacing business that have gotten nervous about the MoM issue.  The really experienced surgeons are getting 98% success over a 10 to 15 year period (generalizing a bit here from McMinn, and others).  Metallosis does not make up the whole 2% failure, but it does make a good portion of it, which is generally thought to be related to steep cup angles.  Not sure about the ambient radiation thing.

2.  Posterier is very common and many patients have really good and quick recoveries from the posterier.  There is a fair amount of discussion on this topic on the forum.  I don't think much is cut, the gluts are speread apart.  I don't recall having any lingering muscle repair issues from the posterier approach.

3.  The THR warbles out of the femur with excessive impact, like running, or side to side cutting.  There are stories of folks doing quite of bit of heavy activity on THRs, but that's not common and many of ortho surgeons recommend not continuing whit heavy/impact activities on a THR.  I think many of us here are expecting to take our HR hips to the grave at a ripe old age, and so do many surgeons.  Certainly, we don't have empirical data saying this, but there is the 20 yr McMinn patient with a BHR leading the pack with no signs of trouble.  We all hope we will only need one surgery (well, 2 for bilats, but you know what I mean).

4.  Indeed Pritchett is always looking into new materials and new devices.  However, often times insurance will likely only pay for the common devices.  Luanna can provide some detail on the Stryker poly cup.  There are some anterior surgeons that I've seen talked about here.  Hopefully you'll see some info come in.  Not too sure about the non MoM aspect though.

Good luck.

[hernanu]

According to the Australian registry (done over 10 years):

(Quoting from the Australian report)

"The main reasons for revision of primary resurfacing hip replacements are loosening/lysis (34.8%), fracture (32.3%), infection (8.0%), metal sensitivity (8.0%) and pain (5.6%) (Table HT63)."

and about the overall revision rate in Australia over the course of ten years:

"The cumulative percent revision at ten years for primary total resurfacing hip replacement undertaken for osteoarthritis is 7.5% (Table HT62 and Figure HT35"

(Both from page 105 of the 2011 report). What this says is that over the course of ten years, whether from improper placement of the devices, infection, fracture, all possible sort of medical reasons, 92.5% of the devices were still in place and functioning well. The revision rate over each year was about 1.2-1.5% per year.

So at least in the Australian study of both HR and THR, the cause of revision distribution is mostly due to Loosening / Lysis and neck fracture for a combined 67.1%, followed by both infection and sensitivity at 8% each.

So in the 10 year Australian study, of all the revisions, the cause by metal ion problems was 8%. This does not make solving metal ions in our favor unimportant, since 8% is significant, but it does serve to put it in context.

[obxpelican]

One thing you might want to do a search on is stress shielding, it's a problem too with THRs.

And as someone else had mentioned, a revision to a THR can be a significant event as the doctor sometimes has to fracture your femur to get the implant out.


Chuck