I wanted to write a summary I would have liked to have found early in hip surgery investigation, and hope this helps the reader. No surgery is without risk. I’ve learned over the years that the best surgeons recommend no surgery unless absolutely necessary, and after conservative treatments are tried. Rehabilitation is still required when doing a surgery. That same effort on its own may fix your issue. I’ve personally rehabilitated multiple issues (not hip), some repeats, without surgery in the face of reputable surgeons recommending unnecessary surgery.  I’ve also had necessary surgeries to perform well again. With that said, I had no choice in getting left hip surgery on March 15, 2021 at the age of 61. Beating major osteoarthritis into submission was a losing battle.

 

The Surface Hippy website was indispensable in learning about hip resurfacing. I spent the entire 2020 year researching hip surgery options including reading detailed published papers by international medical authorities and watching videos and presentations on many related subjects and techniques. Select a surgeon you believe is bright, physically coordinated, has the best qualifications, has experience in many identical surgeries with outstanding recorded surgical data, and uses what you believe to be best implants. Big healthcare practices and misinformation may steer you into a surgery that isn’t your best option. Today, a person has to take charge of their healthcare.

 

Total Hip Replacement (THR)

Most surgeons today, excellent ones too, steer hip osteoarthritis patients into a conventional THR which will amputate a heathy femur, press fit a stem down the middle of the remaining femur to support atop a ceramic ball received into a highly cross linked polyethylene lined acetabular metal cup. The acetabular cup body-side convex surface has rough titanium for bone grow-in, and the cup may have strategically spaced hole(s) to support screws (if needed) for better fixation in the pelvis of some patients. The stem also has titanium for bone-grow-in. The ceramic ball is considered a material accepted well in the body that has little friction in a body fluid setting when moving within the lined cup. Such components can last up to 20 years, but will break down earlier from use and friction, particularly in active patients. More parts and a plurality of different substances are introduced into the body with a THR. Polyethylene can cause osteolysis (body tissues rejecting the polyethylene) as wear particles occur, but healthy individuals without such an allergy (most people) do well. There is a resulting unnatural downward force being placed inside the femur and eventually skeletal degeneration occurs around the femur upper outer perimeter adjacent the stem. The size of the ceramic ball is usually smaller than your original skeletal ball, so future dislocations and lack of stability can be an issue for athletic pursuits. Your brain may require adjusting to new circumstances for even a well done THR installation. There will always be physical limitations with a THR. If there is ever need for a revision of the femur stem, there’s less bone to work with for installing a new stem down remaining femur. A failed THR can be a complex revision surgery.

 

Hip Resurfacing Arthroplasty (HRA)

A great surgeon will steer a healthy patient with early onset of osteoarthritis into a HRA if the patient is young, active in high impact activities, or cannot afford a physical limitation. The HRA involves removing the femur from the socket and resurfacing it to fit a rounded metal cap received into an acetabular cup similarly to a THR, except typically the metal cup not having a polyethylene lining. The Birmingham Hip Resurfacing (BHR) components (femur cap and pelvis side cup) developed by UK’s Dr. McMinn is used by most hip resurfacing surgeons. Various competing hardware of similar design has appeared. Most surgeons use glue at the femur cap underside to affix the cap to the femur top. Both components are made of a high carbide metallic material, so they can last a lifetime of the patient. Natural body fluids provide a lubricant layer preventing excess wear between adjacent surfaces. Minimal parts and minimal different substances are introduced into the body. The metal alloy used can cause metallosis (body tissues rejecting a particular metal content in the alloy) as wear particles occur (i.e. metal ions), but healthy individuals without metal allergies (most people) do well. There is a resulting natural downward force being placed at the top of the femur. The size of the cap on the femur head usually matches your original skeletal ball, so future dislocations and lack of stability is no new issue. Your brain requires little to no adjustment to circumstances for well-done HRA installations. There are no known physical limitations with a HRA. A THR remains a good option if for any reason the HRA fails. An HRA is never an option after a THR. Bo Jackson’s THR failed. I think Bo would have remained a football and baseball star if he got a HRA which is available today. If there is ever need for HRA revision of the femur cap, a femur side THR design can be performed into the existing HRA cup. If a revision is needed for the acetabular cup, there is more acetabular body bone to work with from a typical HRA cup than a THR cup (THR cup lining adds to cup thickness which requires more bone removal to install). So, the HRA always preserves more “bone stock” as read in many journals, and on both the acetabulum cup side as well as the femur side.

 

Hip Replacements (THR or HRA)

Regardless of a THR or HRA, the condition of a particular patient and quality of installation directly impacts the life, wear, and success of the replacement. Choose a surgeon wisely! All angles of a properly fitted acetabular cup must prevent the new femur ball (i.e. HRA cap or THR ceramic ball) from causing more force most the time at cup edge(s) than toward the middle areas of the cup, and the new femur ball (i.e. HRA cap or THR ceramic ball) should emulate as close as possible the position of your original skeletal ball relative the new cup. Every person has a unique anatomy. Leg length issues, component position or angle errors, poor component manufacturing, and other risks can occur with any hip surgery. Great surgeons with skill for art and science will perfect a hip replacement and avoid errors, and they’ll have a history of data to prove it. A THR is less risky than a HRA, takes less time, and is a well understood and practiced surgery successfully performed by even an average surgeon. A total hip replacement amputates the femur thereby creating space to work for completing the surgery. HRA requires more surgical skill and experience in removing the femur from the socket to complete an HRA surgery. There’s no question a THR is a celebrated innovation during the last century when performed well for most people, but young THR patients will likely have limitations and outlive the hardware which can require a revision later.

 

I’ll take heat for what I’m about to say, but political correctness has no place in making a proper healthcare decision. HRA (Hip Resurfacing Arthroplasty) and THR (Total Hip Replacement) is coded identically as a hip replacement to healthcare companies for facility and practitioner reimbursement. Why would a sensible surgeon want to train for more skill, take on more risk, and spend twice the time doing a more complex surgery, yet be compensated exactly the same amount?! The economics of a HRA over a THR doesn’t compel a sensible surgeon with average skill to learn how to do an HRA. And, in our crazy world of misinformation, metallosis concerns are spread around in the hip replacement industry to fortify support in surgeons giving economically justified THR advice. Manufacturers sell more in THR parts. Metallosis concerns associated with HRA are influenced by botched surgeries using metallic components not ideally installed, the patient not being well qualified for a surgery (e.g. HRA on female with small bones), an atypical allergy for metal(s), or component(s) being poorly manufactured. Many metallosis concerns originated from older versions of metallic THR components which got replaced by the THR ceramic and polyethylene configuration described above. I’m confident that HRA metallosis toxicity is over-estimated and under-supported. If you’re a healthy large boned male under 65 years old with hip osteoarthritis (females should consult doctor for applicability), please don’t let an economical misinformed healthcare system amputate your healthy femur.

 

A surgical approach refers to where the initial incision is made to subsequently work the hip replacement. Most surgeons do a posterior approach (from the back) which may provide safer options if something becomes unanticipated during surgery. Every surgical approach to do a HRA or THR will require cutting and later re-joining major tendon/muscle tissue, except an anterior approach (from the front). An anterior approach separates muscle fibers and avoids outright severing major tissues. An anterior approach is being used by more surgeons today than past for THR so patients are back full swing sooner with less healing time. I’m not aware of anyone doing an anterior approach to perform HRA. A trusted surgeon is far more important than surgical approach.

 

Selected Surgeon

People ask me how could I leave such a medically affluent Dallas Ft. Worth (DFW) area and go to Columbia, South Carolina to get hip surgery. I even discovered a prolific Texas hip surgeon found on Surface Hippy who successfully did both hips with HRA on a friend of mine. Every surgeon in my vicinity I consulted, including him, recommended a THR for reasons of age or metallosis risk. I’m a young 61, and the metallosis nonsense being spread around is misinformation affected by poor relevance cases. I wanted no athletic limitations, and a THR option remains after HRA anyway. I wanted surgery in the United States, so I boiled down the universe to four HRA experts (in alphabetic order; and I’m sure there’s other to consider today):

 

Dr. Peter Brooks

Cleveland Clinic, Ohio

BHR un-cemented acetabular cup and cemented femur cap

Lateral approach

 

Dr. Thomas P. Gross

Columbia, SC

Biomet un-cemented acetabular cup and un-cemented femur cap

Posterior approach

 

Dr. James Pritchett

Seattle, Washington

Synovo ceramic coated hardware, un-cemented acetabular cup with replaceable highly cross linked polyethylene bearing like total hip replacement, and femur cap

Superior/Lateral approach

 

Dr. Edwin Su

New York, NY

BHR un-cemented acetabular cup and cemented femur cap

Posterior approach

 

I selected Dr. Thomas Gross. Dr. Gross was easily accessible by phone for free and exudes passion for his work. He had a wealth of expertly published data supporting his HRA practice, and performed more HRA’s than anyone on the planet. It seemed sensible to limit the number of foreign components and different substances in the body, and to avoid attaching parts. Dr. Gross’ solution uses a cobalt chromium acetabular cup and femur cap, each with coated rough titanium at areas contacting bony surfaces for bone to grow in and become one. No glues or screws. Risk of the titanium coating separating from either components seemed minimal given that coating technique is used universally in many body part replacements, and cobalt and chromium do naturally occur in the body. Metal alloy ions can be detected with blood tests (recommended at 2 years post-op) and the body eliminates presence of those naturally. Metal ion levels are directly correlated to proper installation angle parameters — no worries when Dr. Gross does the install. I did find at least one well known surgeon claiming on video that bone has a likely opportunity to grow into the convex surface of an acetabular cup, but is unlikely of growing into a concave surface of a femur cap – that was also debunked as misinformation. I liked no cement on any component. Dr. Gross also has a THR back-up plan in the rare event the femur side needs revision to be received in the existing HRA acetabular cup. Dr. Gross is a true pioneer perfecting HRA as an outpatient surgery.

 

Dr. Edwin Su is known for having performed HRA on a number of celebrities. I watched his surgeries and presentations, and find him articulate and meticulous. Dr. Su required an in-person appointment to initiate discussion. We were in a Covid environment at the time, in particular in New York. Dr. Su was completely inaccessible.

 

Dr. Peter Brooks was easily accessible by email for free, and exuded passion for his work. I preferred the no cement Biomet hardware over the BHR, and a lateral approach seemed less used by other surgeons, but those may be poor reasons for not selecting Cleveland based Dr. Brooks.

 

I thought Dr. Pritchett was accessible for free until I received a bill later for the initial video conference consult. It may have been a misunderstanding. He also exuded passion for his work. Dr. Pritchett has an interesting design and a wealth of expertly published data supporting his HRA practice, as well as many accessible videos. His marketing media exceeded others. The acetabular cup and femur cap is coated with a ceramic material to eliminate metallosis being a concern in any patient. The acetabular cup has a replaceable highly cross linked polyethylene lining (referred to as a bearing which he says has “never had to replace yet”) for most closely matching natural hip performance (Dr. Pritchett refers to as “sports hip”). He also claims a number of reputable THR surgeons being his HRA patients (economic healthcare hypocrisy exposed!). Risk of the ceramic coating separating from either components seemed possible given that coating technique and Synovo hardware is only accessible to Dr. Pritchett. Some other surgeons expressed concern that the polyethylene lining in the resulting thicker acetabular cup component requires additional acetabular side bone loss to install. Those may be poor reasons for not selecting Seattle based Dr. Pritchett.

 

The Dr. Gross surgery

Every aspect including logistics getting a HRA by Dr. Gross was well organized, well-staffed, timely, and managed like a well-oiled reproducible machine whether you were local or visited from anywhere in the world. That includes before surgery, and as needed after surgery. Local hotels are integrated in the process. His entire practice was remarkable and my result is outstanding. When I met Dr. Gross in person before surgery, I could no longer hide a limp and had severe pain even standing. He has all the qualities I want in my surgeon.

 

Dr. Gross was likely surprised during my pre-surgical appointment prior to surgery at my response of “No” when asked if I had any questions. I felt I knew him and HRA well by that time, and frankly I felt this was my last chance to return to an active life worth living. Everything communicated to me about the prep and the after-care was as planned. I’m tall and larger than most, so the only snafu occurred when hotel staff provided a poor excuse for a post-op toilet seat adaptation. A call to Dr. Gross’ staff immediately fixed that issue. My wife and I drove from DFW Texas to Columbia, South Carolina to avoid any chance of catching Covid on a flying petri dish. We had a hotel one night stay halfway there, and back to DFW, with post-op days in Columbia. It was a long drive, but I’d do it again in a heart-beat if my right hip needs Dr. Gross in another pandemic. Use the ice machine — it works well. Other post-op tools provided were also great.

 

After a couple months rehabilitating and healing, I developed clunking in the left hip when the post-op hip leg went from flexion to extension during walking, and that stayed with me for a year every time I walked. There was never pain associated with it, but it was unnerving. I became obsessed with leg length mismatch based on how I felt and measurements I’d take in all kinds of positions, but there was no leg length issue. My left hip area was so weak from years up to the surgery that it took lots of time and extra work to overcome strength and pelvic imbalance issues which others either don’t have to deal with, or overcome sooner. After a year into my rehab process, I injured my knee in a moment of underestimated athleticism. This set me back in returning to sports and running. Clunking went away and became a snapping hip syndrome diagnosed as the IT band catching over the greater trochanter. This was hip area atrophy and weakness from years of osteoarthritis and FAI before doing surgery. Stretching hamstrings and quads, as well as strengthening the left hip and leg has been most beneficial. I do deeper quality leg stretching and have returned to regular walking, weight lifting, and unlimited activities.

 

Today is 28 months HRA post-op with Dr. Gross. The snapping hip went completely away 6 months ago. People who report snapping or clunking should know IT WILL GO AWAY, perhaps taking longer for some. My hip operates like it did when I was young. I have no limitations in any activities, and I’m very active. As expected, there were no elevated metals in my 2 year post-op metallurgy testing.

 

Trust the Dr. Gross process. Invest extra time and effort to rehabilitate a particularly weak hip. Don’t wait years to get treatment. A surgical miracle deserves the commitment to improve one’s condition. Dr. Gross can work a miracle for your hip.