Kasier Girl

It is simple why all doctors don't recommend a hip resurfacing.  Either they don't do it or are not educated with up to date information. There are some that have done them and are educated and just don't think they are a good solution.  It is a bit like - should I buy a FORD truck or a CHEVY truck.  If you sell Fords, you are not going to recommend a Chevy. There is a lot of politics involved and some is based on the very negatively biased information by the media.  The national registries are the best source to see the retention rates.  They are excellent for the BHR and in some cases for certain selection of patients - better retention rates than THRs.  All of hip replacement is constantly changing.  There is no perfect hip replacement since you can't duplicate the human body.  So doctors and companies continue to design devices.  You make the best selction of what is available when you need it.  Look at computers - 15 years ago no one thought they would have an I Phone that could do as much as a small computer.  Techniques and devices continue to develop and you have to choose what is best at the time.

It is a fact, most orthopedic surgeons don't recommend hip resurfacing.  It is also a fact that many are not skilled enough to do them and choose not to.  That is good for the patient.  You don't want a botched hip resurfacing.  If they can't do them, few will recommend them.  They want you as a patient and will do what is most comfortable for them and what they are use to doing.  Few people in this world are adventerous and depend on the tried and true - if all did that, there would be nothing new.

Pat

PS Place particular weight on Pat's posts.  ;)

Quote from: Kaiser Girl on May 19, 2011, 01:14:36 AM
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?

It is the resurfacing that might well last. The articulating surfaces of MOM THR and resurfacing might be similar, but the 'stress shielding' you get from a THR weakens what is left of your bone.

You do not need to get resurfacing because you think the revision will be easier, you get it because you should never need revision.

Choose a good device and a good surgeon. Choose the best device and the best surgeon.

Thanks for your question:  "Do you wish you had a THR yourself?".  It's simply too early to tell, as I am only 11 weeks out from my resurf.  Perhaps I will have a clearer answer in a year or so.  I saw several prominent surgeons in my area.  One thought I would be best served with a ceramic on ceramic bearing THR, but he cautioned that I probably should not ever run or do high impact sports again.  I had already been aware of the problems with ceramic bearings (ie fracture etc), so in any case I wasn't interested in that option.  Metal on poly is probably the safest of options as it's been around a long time; I was worried that if I was too active on that bearing I might wear it out quickly.  I was also worried about dislocating because a metal on poly usually requires a 28 or 32 mm head, and the smaller diameter head has less length to travel before dislocating from the cup.  My problem with the large head metal on metal articulation, be it resurf or THR, is the not insignificant numbers of patients with groin pain that are being reported by many centers.  That scares me.  Because I have good bone stock, I am not terribly worried about a femoral neck fracture, although they say that it can happen anytime within the first 6 months . . . so far so good.  To Pat's post about her having videos, registry proof etc etc:  I will say again:  There isn't any good objective scientific evidence that resurfaced people are being more active than THR folks; in fact most studies of both types of replacements simply do not quantify numbers in this very important area.  This is an area of research that is ripe for some good objective study, and to date the only head to head (pun intended) study of resurf vs THR showed no difference in activity levels.  We need to get away from the "my neighbor had this type of implant and now he's paralyzed" comments so that we can really be of service to each other on this site.

Quote from: Kaiser Girl on May 19, 2011, 01:14:36 AMWhy not get the correct surgery now and never need a revision?  Am I too Polly-Anna on this one?

I think so, but that's just my opinion.  

Quote from: Eitan
I will say again:  There isn't any good objective scientific evidence that resurfaced people are being more active than THR folks; in fact most studies of both types of replacements simply do not quantify numbers in this very important area.

http://www.orthosupersite.com/view.aspx?rid=83509

ORTHOPEDICS TODAY May 2011
Study finds hip resurfacing offers clinical benefits over total hip

Despite being proclaimed as “The operation of the century,” total hip arthroplasty is far from an ideal procedure. In fact, one study found that “in spite of a good hip score, only 43% of patients had all of their expectations completely fulfilled,” said Robert L. Barrack, MD, chief of service, Orthopedic Surgery, at Washington University School of Medicine in St. Louis, Mo.

Although patient selection is rarely an issue with total hip arthroplasty (THA) and the surgical technique “is more forgiving,” selection and technique are major issues with metal-metal hip resurfacing replacement arthroplasty (SRA), according to Barrack, who spoke at the Current Concepts in Joint Replacement 2010 Winter Meeting. The indications for SRA are also “narrower, the implant is more expensive, and the technique is more demanding and less forgiving.” To justify the use of SRA rather than THA, Barrack noted, there should be some objective clinical advantage.

Barrack was part of a recent multicenter study that evaluated the current level of success and function of modern hip implants in returning high-demand patients to crucial activities. A modern implant was defined as an uncemented tapered titanium stem combined with an advanced bearing surface or a surface replacement.

Data collection

All patients were younger than 60 years old with a high demand (a premorbid UCLA score greater than 6). A novel method of collecting data was also employed.

“It was completely unbiased and blinded,” said Barrack, consisting of a phone questionnaire to evaluate functional outcome among hip implants at a minimum of 1-year follow-up.

Patients were from one of five geographically diverse medical centers, each with expertise and experience in various types of advanced bearing surfaces, and had a cementless tapered titanium stem with ceramic-ceramic, metal-metal (standard and large head), metal on cross-linked polyethylene or a surface replacement.

Moreover, the study contracted the University of Wisconsin Survey Center as an independent third-party surveyor because of its “long track record in administering health questionnaires for state and federal agencies,” Barrack said. The survey center “had no knowledge or interest in bearing surfaces, so it was truly unbiased.”

The study began with a consecutive series of 1,400 patients, of whom more than 60% completed the detailed survey, for a large sample size of more than 800 patients.

“All of these patients were very successful with modern implants in returning to employment â€" over 90% in every category of work, even for heavy and very heavy activity according to Department of Labor categories.” Barrack said. “There was no difference in implant type.”
Perceptions

However, patients who underwent SRA were much less likely to perceive a limb length discrepancy, thigh pain or to limp in comparison to their THA counterparts. SRA patients were also more likely to run for exercise, run longer distances, and walk for longer distances as well.

Conversely, SRA patients “had a higher incidence of noises emanating from the hip than other bearing surfaces, although this was transient and asymptomatic,” Barrack said.

In addition, bone density testing in a select group of SRA patients revealed substantially less stress shielding in the proximal zones at 6 months that continued to improve at 1 year. Therefore, “we now allow these patients full activity at 6 months,” Barrack said.

In conclusion, SRA demonstrated objective evidence “of a higher level of function and satisfaction compared to a similar THA cohort in limp, walking, running, perceived limb length equality, and thigh pain,” said Barrack, who advocates continued use and investigation of SRA in selected patients. â€" by Bob Kronemyer

Thanks einreb, very interesting.

At the present, there seems to be no clearly "right" answer on the resurfacing vs. THA question.  But there seems to be no clearly "wrong" answer, either.  About the best thing a potential patient can do is make a reasonable effort to review available information, sift out the outlier viewpoints, and then make a decision.

To add to the discussion, here is an abstract of study which found that there is a a "significantly higher postoperative activity level" in resurfacing patients as compared to THA patients.  Note that, according to the abstract, patients "with resurfacing arthroplasties were matched to a cohort of patients who underwent conventional hip arthroplasty by gender, age, body mass index (BMI), and preoperative activity level."

http://www.ncbi.nlm.nih.gov/pubmed/19583537

Bull NYU Hosp Jt Dis. 2009;67(2):116-9.

Resurfacing matched to standard total hip arthroplasty by preoperative activity levels - a comparison of postoperative outcomes.

Zywiel MG, Marker DR, McGrath MS, Delanois RE, Mont MA.


Source

RubinInstitute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA.


Abstract

BACKGROUND:

Some studies have suggested that resurfacing patients are generally more active postoperatively than their conventional total hip arthroplasty (THA)counterparts, but controversy remains over whether this is a reflection of preferential use of resurfacing for younger and higher-activity patients. We hypothesized that, when controlling for preoperative activity levels, in addition to relevant clinical and demographic factors, resurfacing provides similar results to conventional hip arthroplasty.

MATERIALS AND METHODS:

The specific question asked was whether resurfacing patients had differences in postoperative activity level, clinical outcomes, or rate of revisions, as compared to a matched cohort of patients treated with conventional THA. Thirty-three patients (23 men and 10 women) who were treated with resurfacing arthroplasties were matched to a cohort of patients who underwent conventional hip arthroplasty by gender, age, body mass index (BMI), and preoperative activity level. Mean preoperative Harris hip scores and length of follow-up were similar for the two groups. Postoperative weighted activity scores, Harris hip scores, patient satisfaction score, pain scores, and revision rates were evaluated at a mean final follow-up of 42 months (range, 25 to 68 months) for the resurfacing group and 45 months (range, 24 to 67 months) for the conventional hip group, and analyzed for differences.

RESULTS:

At final follow-up, activity levels were significantly higher in the resurfacing group, with a mean weighted activity score of 10.0 points (range, 1.0 to 27.5 points), as compared to a mean score of 5.3 points (range, 0 to 12.0 points) in the THA group. Mean Harris hip scores, patients satisfaction scores, and pain scores were similar for both groups. There were no revisions in either group.

CONCLUSIONS:

The results of this study suggest that patients treated with hip resurfacing arthroplasty have a significantly higher postoperative activity level, as compared to those treated with conventional THA, when controlled for preoperative factors.


PMID: 19583537 [PubMed - indexed for MEDLINE]

Thanks for the articles and links.  Very interesting.  They will be part of my discussions with several MDs over the next few days.  I'm hoping that the choice will become clear to me by sometime next week.  Dr. Klug is patiently waiting for my response... It's true, there is no right or wrong choice for me.  I am fortunate enough to still be healthy/strong enough that I will do well with whatever device I get.  I just don't want to have any regrets later. 

Quote from: Kaiser Girl on May 20, 2011, 01:41:14 AM
It's true, there is no right or wrong choice for me.

Really?

Lopsided, from what I've been told, I will do very well with whichever insert I get.  I'm young, healthy, active.  I'm not so much worried about the present.  I'm trying to control the future (ha, ha) by trying to pick the device which will be the least likely to need a revision. 

I'm also a surgery virgin so am reluctant to jump in to bed with any surgeon doing whatever surgery he thinks is best.  I need to be 100% behind the surgeon and surgery.  This is no easy decision for me.

And, btw, clearly you are braver than I.  First uncemented Conserve Plus for your doctor?  That is a courageous claim to fame, in my opinion.

K Girl,

I am glad you are young and healthy, and you may well recover well from any operation. There are, however, most definite right and wrong choices. And your health and strength does not mean that you will do well with any device, it means the opposite, that you may wear the device or part of yourself out.

Yes, you want this to be your only operation, and hopefully not need revision. That is what we all want and hope for.

Replacement and resurfacing differ in that:

• A correctly placed and well chosen resurfacing device might well never wear out.
• All replacements have a limited lifetime, because of 'stress shielding'.

I don't know who told you that you will do very well whichever device you get. This is ridiculous.

We all have had concerns over which surgeon to use. It is no easy decision for any of us.

And I am certainly not brave. Much as it seemed obvious to me that I needed resurfacing, it also seemed obvious to me that I should get uncemented. This is another debate. After much research, I chose Dr. De Smet, one of the world's best. Confident in the choice of device, fixation and surgeon, I did not need courage. I committed to it in the belief that it was the single best choice, and knowing that there are no guarantees in life in general.

So do your research, K girl, and you make your choice, as everyone else who is young and healthy here has done too.

Dan

Quote from: lopsided on May 20, 2011, 10:07:41 PM
We all have had concerns over which surgeon to use. It is no easy decision for any of us.

Confident in the choice of device, fixation and surgeon, I did not need courage. I committed to it in the belief that it was the single best choice, and knowing that there are no guarantees in life in general.

lop,

VERY well said. There are no guarantees. I also knew that I didn't want my bone sawed off, didn't want a long, deep hole drilled in my femur and I wanted the device that most closely resembles and functions like a natural hip. That is of course if I qualified for resurfacing. I never once doubted my decision before or after my surgeries. Not one bit! Thanks to you Pat for setting the record straight.

Quote from: Eitan on May 19, 2011, 08:17:53 AM
Metal on poly is probably the safest of options as it's been around a long time

That is madness! In the young active patient there is a high risk of dislocation, wear debris etc. It simply is not fit for purpose, too limiting and will not last.

Dan and Steve,

I agree with everything you guys said.  There are never any guarantees, you have to make the best, most informed decision you can and go with it!

A person that I know with a THR has had a re-occurring problem with the stem in the femur loosening .  Now after revisions they don't want work on   him anymore. This is the main reason I looked into  HR . When I asked my GP doctor about resurfacing, he told me don't get HR , get THR. He was in a hurry and didn't explain why he was against HR. Because of the way he answered, I changed doctor's immediately. This is a big decision and needs more than a 10 second  , slightly arrogant answer. Next doctor I went to  was more open minded and took way more time with me. He prescribed HR to me and now I am 6 weeks post op HR.

I plan to run this piece into oblivion in the next 15 years. My goal is 100 triathlons before I even think about a revision.  I needed a procedure that would give me the best chance at achieving this goal. Everyone has different goals. If I wanted to go to the park and throw around a ball with my kids, I would have done a THR. So I hope HR lives up to hype. It's gonna need it.

Well said, HNH.  Just be sure you leave a sports beverage or two at the finish line for me ... I'll be crossing it right behind you!

Kate

There is a new article on Mr McMinn's website in response to a tv program shown here in Australia.  The article has a look at some of the data that has been discussed in earlier posts in this thread: http://www.mcminncentre.co.uk/response-abc-corners-program.html
Mr McMinn's article is interesting and informative and challenges the media speculation with scientific data. His opinion is that "A well-designed, well-engineered, well-implanted resurfacing is a much better option than a hip replacement."  The article explains why.  Even if you disagree, the article is well worth reading.

(He also reminds us: "Choose your device and your surgeon carefully." - again I agree and believe that I did!)

His reply is not really a criticism of the television program, but more promotion of the Birmingham.

He states that there are twenty brands of resurfacing devices, but only compares the Birmingham to three, ASR, Durom and Corin, that he does not like, two of which have been recalled. What about all the others, are they good in his opinion? Why were there no comparisons with the others?

"Not really a criticism"? No, more of a destruction with data, everyone should check the link, thanks Lori.