Is 26 too young?

[Canadian-Ice]

Hi Mark,

I live the Toronto area and have been reading this site since diagnosed with OA about three years ago. There are surgeons in Ontario who can do Birmingham Hip Resurfacing covered under OHIP and do not cost us anything.

But personally, I want to minimize risk of problems from the surgery and causing an early revision. I'm going to go to Dr. Bose in India who is widely recognized as one of the top surgeons for this surgery in the world, yet costs half that of other private surgeons.

I wish there was hard objective data to support the results of any surgeon. But we have meta data from national registries and data provided by the surgeons themselves. However some surgeons have stellar reputations and if you canvass this and other sites you can hear from enough people, patients and long-time advocates and professionals, and make up your own mind.

If I were 26, I would be willing to pay the ten grand in pursuit of the best outcome possible.

Having looked into longevity, the best data I know of is by the McMinn Centre which reports 98% of young male resurfacings done over 12-15 years in the first cohort of 1000 are still functional. It's implied this 98% do not have any significant pain or loss of function. These are the results of Derek McMinn.

You are wise to raise questions about eventual revision. From what I can gather, hip resurfacing revisions occur for many reasons but in the event of loosening (or hypothetical wearing out) the acetabular side will require a new cup as with a THR.

Basically you would end up with a Revision THR. These last about 12-15 years and do not allow for any impact sports. Each subsequent revision lasts less time and is a more complicated surgery.

No one has ever wound up in a wheelchair as far as I know. But from what I can gather, having a revision THR is bad news for any athlete or highly physical person. Hopefully, though, by the time any of us younger folks requires a revision, technology will allow for a longer shelf life of our second hip.

Any thoughts?

Good luck.

[Dannywayoflife]

If ever required revisions generally are a primary thr not a revision thr.

[Canadian-Ice]

Danny, how do you know that? I did get an email from Dr. Bose that while the bone stock on the femur is preserved the acetabulum bone is not.

This means the acetabulum side requires a "revision" component and potentially bone grafts just as with a second THR.

What causes for revision are you referring to? I'm speaking of the "natural" causes of revision that may eventually come after decades for us all, not the exceptional cases.

[Dannywayoflife]

The subject of acetabular bone loss is a controversial one. Watch the McMinn videos he says that revision of a resurfacing is equivalent to a primary thr. That is one of the beauties of this operation.

Also realistically it's not likely any of us will "wear out" the bearing couple in the bhr. As for the loosening its not an issue as I see it. Look at McMinn or Treacys results and at nigh on 20 years its a non issue. May it be an issue further down the line? Time will tell. 

[Canadian-Ice]

I will take a look at McMinn's video regarding revision. Is this view that a resurfacing revision is to a primary THR including that there is not significantly more bone loss after revising a resurfacing?

If the new device is a THR not a revision device, that is good news. However it still leaves the question of acetabular bone. I've never heard of a resurfacing doctor saying a resurfacing device preserves acetabular bone.

What would be good would be data on THRs that followed resurfacing devices. Playing the devil's advocate, I'm not sure there is much if any consensus in the field on the issue.

[Dannywayoflife]

I'm sure Dr Su has published a study on the matter of acetabular bone loss by weighing the bone resected. I don't think there was much difference between the 2 mate. And as for large head thr's that all the manufacturers are going to there was no difference from my recollection

[Canadian-Ice]

Yes my understanding is there is no real difference in acetabular bone loss between resurfacing and  most THRs. Resurfacing does preserve femur bone, and there may be a few THRs that preserve more acetabular bone than most THRs/resurfacings. So it seems to me that a THR, even a primary THR, revised from a resurfacing will still be a revision insofar as acetabular bone.

This is important, because seems to me that this will affect restriction levels on the new device should (if) the resurfacings ever fail over the course of the lifetime of an athlete.

[hernanu]

Just as an informational point, according to the 2012 Australian registry, the type and proportion of revisions to a failed HR practiced have been:

• Total hip - both acetabular and femoral (53.3%)
• Isolated femoral (38.5%)
• Acetabular only (5.2%)

Apparently this is the first year where Total hips were the top item, before it was femoral.

In my opinion, that may be more a surgeon's choice or a more accepted method now than before.

So based on previous revision choices and even now, a major number of revisions (and before the major number) were femoral revisions. So the acetabulum component once inserted stands a good chance of remaining in place even in the case of revision.

The argument for bone preservation still stands as a good one if the acetabular component is left as is.

And to remind us the largest reasons for failure (of the total cumulative failure rate of 9.5% over 11 years, meaning all failures with all devices (including recalls) and all surgeons over that time):

• loosening/lysis (33.6%) or (9.5 * 0.336 = 3.92% of all HRs during the 11 years)
• fracture (25.7%) - this is mostly limited to the first year in HR (9.5*0.257= 2.44% of all HRs)
• metal sensitivity (16.6%) or (9.5*0.166=1.57% of all HRs over 11 years)
• infection (7.2%) or (9.5*0.072=0.684% of all HRs)
• pain (6.0%) or (9.5*0.06=0.57% of all HRs)

From what I've read, fracture is mostly an issue during the recovery period (0-1 year), with most failures during the first six months.

[Mark.D]

Wow some great information here!

As for going to India I think that will be out of the question. In all honesty what makes some of these surgeons do the surgery so much better? Im sure there should be some very talented surgeons in Canada is there not?? Also NY state is very close to me where Dr Clark is. I have no idea what that would cost though.

[hernanu]

The attraction to travel to India is both the skill and experience that the doctor there has, as well as the affordable prices he charges.

Some folks here have had theirs done there, and given the sheer number and success he's had, despite the distance traveled, he is a very attractive option. 

I understand the distance involved, both physical and mental, but in this surgery, the aftercare does not have to be done by the surgeon in my opinion.

My surgeon thankfully lives near me (one hour's drive), but to tell you the truth I would easily have traveled to New York, South Carolina, Cleveland or any place that would let me have the best chance at a good, successful HR. Pat, who runs the site travelled to Belgium to have hers done as several of our hippies have.

There are many good surgeons that you can reach, but as with everything, your circumstances both personal and financial will influence the choice.

The important thing to me in making sure this is done right is to choose the best possible surgeon, who fulfills these criteria (again my own opinion) :

• Experience. Has to have done at least 2-300 HRs. Mine had done 800 at the time of my first
• Committment. He can't be a dilettante. He or she has to endorse HR, believe in it and be actively intelligent in explaining what will be done and why.
• Frequency. Can't have done one per month. My surgeon was doing three per day. No matter the skill, in my mind the less repetitions, the less effective. Would you hire a mechanic that did mostly bicycles, but fixed cars once a month? How much more important is your body
• Aftercare. The surgeon has to have a plan in mind not just for the procedure, but also for the recovery. Different surgeons have different plans that they believe in, but they must have a plan that makes sense to you.
• Skill. Demonstrated by results. Quiz them about number of successes, how many failures and ask about what happened with the failures. They are not gods, each has failures.
• Connection with you. You are entrusting your hips in a complex operation to this person, you have to feel a good trusting connection to them and their staff

Again, one thing that is clear is that the most important choice is of a good surgeon. The choice of the device if he's a good surgeon is probably going to be good also, since they are aware and practiced in which devices they believe work well.

You've been given some good choices in Canada, I think we've had several folks here who have successfully had HRs there. The US and overseas choices are also good ones if they fit personally and financially, but again - only if it's a good, successful surgeon and facility.

[Dannywayoflife]

Personally I would have travelled the length of the globe to see a top surgeon it's THAT IMPORTANT!