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Dr. Thomas Gross
4000 Hip Resurfacings to date***
3000 Uncemented Hip Resurfacings
200 Outpatient Hip Resurfacings
South Carolina Joint Replacement Center
1910 Blanding Street
Columbia, S.C. 29201
Lee Webb, MSN, APRN, ANP-BC
Assistant to Thomas P. Gross, M.D.
803-256-4107 office, 803-355-2774 pager
803-331-6894 cell, 803-933-6754 fax
Contact email: Ms. Lee Webb, MSN, APRN, NP
South Carolina Joint Replacement Center
The continuing controversy – Thomas P. Gross MD. 7/4/2015
Young women who desire a more functional hip replacement were recently dealt a large blow when the smaller sizes of the Birmingham Hip Resurfacing (BHR) device were withdrawn from the market by Smith Nephew Richards because the 10-year revision rate for women was higher than for men in most large registry analyses. (The major national registries are Australia, Combined Scandinavia, and Great Britain).
Joint implant registries estimate an overall failure rate for different implants when used by the average surgeon in a country. Specialist surgeons can typically perform better than these data suggest.
Hip resurfacing is a treatment for severe hip arthritis that results in a nearly normally functioning hip. Scientific studies demonstrate that patients walk more normally in gait studies, and are more likely to be able to resume full impact sports if they have a hip resurfacing rather than a traditional stemmed total hip replacement.
Generally women have smaller hip joints than men and require the smaller sized implants. There is no way to make the larger ones fit. The only alternative, if no smaller sized hip resurfacing implants are available, is to amputate the whole femoral head and then perform a standard total hip replacement (THR). I would estimate 70% of women and 20% of men will now not be able to choose a hip resurfacing arthroplasty (HRA).
It is difficult to know from the preoperative x-ray for certain what implant size will be needed. If patients are now scheduled for a BHR, they may end up with a standard stemmed THR instead of a resurfacing once the surgeon
has opened the hip and found that the hip requires a smaller size than they thought.
There is no doubt in young men. Resurfacing is more functional and more durable. All men under 60 should have resurfacing if there were enough qualified surgeons available.
In women there is a dilemma: Do you choose a more functional hip that has a higher chance of failure by 10 years? Unfortunately women are loosing the opportunity to decide for themselves. The decision is being made for them by implant companies and the policies promulgated by the FDA. On the other hand, the failure gap between men and women is much lower in the hands of experienced resurfacing surgeons (than in registry data) My data now shows a 98% 8-year implant survivorship in women. Very few THR studies can match this in young patients.
Men requiring smaller bearing sizes and women desiring HRA have several options:
1. Leave the country for surgery. The Conserve Plus was withdrawn from the US market because of our overly litigious environment after Wright Medical was bought by Microport, a Chinese company. This implant has an excellent track record. Just before being sold they released an improved acetabular component that increased the coverage arc of all acetabular sizes to 170 degrees, which addressed the problems with smaller implant sizes. It is still available worldwide, but the company will no longer sell it in the US.
2. See Dr. James Pritchett (Seattle) who performs a HRA with a ceramic on polyethylene device. The socket component is thicker than metal bearing implants. Therefore, implanting these requires more bone removal. Also previous results with standard polyethylene in the 1970s was poor. Cross linked polyethylene has not yet been adequately tested, but shows promise in preliminary testing. Currently cross linked polyethylene is not available for resurfacing.
3. I still perform HRA using Biomet metal bearing implants for all patients. I have similar results in men and women and also perform resurfacing in patients with difficult deformities. I have performed over 3700 HRA with Biomet implants since 2005 with an excellent track record. Results are published on my website.
What is the problem with HRA in women?
10-year implant survivorship in young men is superior for HRA as compared to THR.
Implant survivorship in women and men with smaller bearings is lower than THR in large registry studies.
Implant survivorship is not the only criterion that should be used to decide whether THR or HRA is best. Furthermore only the patient and their surgeon should make the decision as to which operation is best for the patient. The government, insurance companies, hospitals are not qualified to make this decision. Orthopedic societies also should not make blanket policies, because they are not the treating physician and they are typically controlled by a group of surgeons who have strong biases of their own. Surgeons who politically control these societies are well-respected, but do not necessarily have greater knowledge or skills than any other surgeon.
If, based on registry data, HRA should be made unavailable to women, then by the same reasoning THR should be made unavailable to young men under 60. Neither of these make sense, the decision in each case should be made by the informed patient with the guidance of their chosen surgeon. Surgeons need to keep accurate data and inform patients of their track record with different procedures. My 8-year implant survivorship with the Biomet uncemented resurfacing is 99% for men and 98% for women in over 3000 cases.
Why do women have a higher failure rate with HRA as compared to men?
The answer is multifactorial.
1. Dysplasia is much more common in young women with end stage hip arthritis. Both THR and HRA have worse outcomes for dysplasia. A direct comparison of THR vs HRA has never been done for dysplasia patients. Before 2008 I had a 82% 8-year implant survivorship rate for dysplasia now I have a 99% 8-year rate. Problem solved. I have not seen any comparable results for THR.
2. Adverse Wear Related Failures (AWRF) are more common with smaller implant sizes. Women require the smaller sizes. We have shown that AWRF can be avoided by proper acetabular component positioning. Prior to 2009 we had a 1% 10-year rate of AWRF; I have not had a single case of AWRF since 2009 in over 2000 consecutive cases. Problem solved.
3. Failure of Bone Ingrowth of acetabular component is more common for severely deformed sockets (such as some dysplasia cases). This was my most common failure mode in dysplasia cases previously. In 2007 the Biomet Trispike Magnum was released. This implant has spikes for supplemental fixation. I use it in the worst 5% of Dysplasia cases. I have had no failures of fixation in any dysplasia cases since 2007. problem solved.
4. Femoral neck fracture occurs more commonly in patients with weaker bone. fracture only occurs in the first 6 months after surgery. Women have weaker bone. Since 2007 we have been measuring bone density on all patients and use this to adjust postoperative management. We have had no femoral neck fractures in 2000 consecutive cases since 2009. problem solved.
5. Uncemented femoral components have eliminated late loosening as a failure mode up to 8 years so far. this has improved results in men and women.
Advantages of hip resurfacing:
1. Better implant survivorship in young patients. women now have very similar results as men. Hip resurfacing done by an expert is more durable than THR for men and women.
2. Better functional outcome. Impact sports are much more commonly possible after resurfacing. Also, formal gait lab studies always show more normal function for resurfacing. If you want to play sports, you are much more likely to do so with a resurfacing.
3. Better stability. Dislocation rates are much lower for resurfacing because biomechanically a resurfaced hip is closer to a normal hip. In THR the bearing size is artificially smaller, leading to a higher risk of dislocation. With HRA there are no worries with extreme range of motion activities such as yoga, gymnastics or kayaking.
4. Better patient survivorship. Two large studies based on the British implant registry have shown that resurfacing patients are much more likely to be alive at 5 and 10 years after surgery than age, gender and health status matched groups of patients who receive THR. Resurfacing patients can tolerate more vigorous exercise which may keep them healthier and alive longer.
5. No thigh pain. 3-5% of THR patients have thigh pain due to irritation from the stem. This does not occur in HRA. This may be the reason that function is generally poorer with THR.
6. Bone preservation. Much less bone is removed from the femoral side with resurfacing. Socket side bone removal is the same for both procedures. Removing a well-fixed femoral THR stem can require splitting the top of the femur, a resurfacing is removed by cutting the neck off, just as one does in a primary THR operation. Bone preservation in young patients leaves them better future options.
7. Philosophical. If you have lost your cartilage layer, why not just replace it with metal and leave the hip as close to a natural hip as possible? Amputating the head and neck, driving a spike into your femoral shaft, and leaving you with a biomechanically unsound smaller hip bearing just doesn’t seem right.
Disadvantages of hip resurfacing:
1. Technically difficult. it takes a few hundred cases to master. some surgeons just don’t have the ability to take this on. Most surgeons learn THR in residency, few learn resurfacing. Now surgeons are scared to learn because of all of the misinformation about adverse wear problems.
2. Adverse wear related failure. This is the main argument against it by THR advocates. This is totally preventable by proper implant positioning. I have had no cases of AWRF in over 2000 consecutive cases since 2009.
Total Hip replacement has been called “the operation of the century” because of its dramatic impact on society. But that was the 20th century. Hip resurfacing is the operation for the 21st century!
Write to your congressman and let him/her know that the FDAs needs to lighten up. just because some surgeons have difficulty with resurfacing, does not mean that these implants should be removed from the market. Resurfacing has been shown to result in a more normal functioning hip reconstruction than THR. Failure rates have been higher in women in the past. But we have discovered the causes for these higher failure rates and have addressed them. There is no reason to abandon resurfacing in women. In the hands of experienced resurfacing surgeons the failure rate in women now approaches that of men.
Write to Smith Nephew Richards and let them know that you are disappointed that they removed BHR implants for women from the market. Women want a high functioning hip option as well.
If implant companies modified the smaller implant sizes to increase the coverage arc to 165 degrees, AWRF would rarely occur, even in the hands of less skilled surgeons. If the FDA did not make the approval process so onerous and costly, implant companies might consider taking this approach. this would be a better approach than just withdrawing implants from the market
Visit me at www.grossortho.com for more information
Dr. Gross Interview by Patricia Walter Dec. 3, 2012 in Columbia SC
Resurfacing vs Total Hip Replacement 2012. Video
addresses answers to the negative media blitz against
Dr. Gross Interview by Patricia Walter Dec. 3, 2012
Dr. Gross Interview by Patricia Walter Dec. 3, 2012 Columbia SC
Part 1 – Dr. Gross Interview by Patricia Walter
August 26, 2011 in Baltimore, MD at the 5th Hip Joint Course
Dr. Gross is interviewed by Patricia Walter in Baltimore, MD 2011. Dr. Gross discusses the negative press coverage of hip resurfacing, metal ions, metal allergies, positive outcomes of hip resurfacing patients, cementless hip resurfacing, Biomet device and active patient recoveries.
Part 2 – Dr. Gross Interview by Patricia Walter
August 26, 2011 in Baltimore, MD at the 5th Hip Joint Course
Dr. Gross interviewed by Patricia Walter in Baltimore, MD 2011. Dr. Gross discusses metal ion issues, negative press against hip resurfacing, cementless resurfacing, Biomet Device, patient selection and patient outcomes.
Dr. Gross Interview by Patricia Walter
Sept. 5, 2009 in Baltimore, MD at the 3rd Hip Resurfacing
Dr. Gross of SC is interviewed by Patricia Walter in Baltimore, MD 2009. Dr. Gross discusses hip resurfacing and cementless hip resurfacing. He describes patient selection, hip resurfacing outcomes, Biomet Hip Resurfacing Device, post op outcomes and surgical approaches.
Dr. Gross Video Interview by Patricia Walter November 13, 2008
Dr. Gross interviews about hip resurfacing by Patricia Walter in Columbia, MD 2008. Dr. Gross discusses hip resurfacing, patient selection, cementless devices, Biomet Devices, post op recoveries, surgical approaches and outcome of hip resurfacing.
HIP RESURFACING SURVIVORSHIP
Thomas P. Gross, MD 2480 cases over 10 years August 2011
Survivorship of hip resurfacing continues to improve as we gain more experience and find measures to prevent failures. Theses survivorship curves give the reader an opportunity to see what the odds are that their implant will still be functioning at some time point after implantation. We have used three implant systems in the last 10 years. The first were hybrid fixation Corin devices (blue), the second were hybrid fixation Biomet devices (red), the latest are completely uncemented Biomet devices (green).
In the last 10 years we have learned what patients with particular characteristics are at higher risk for failure. The strategy of many experts is patient selection. If they avoid performing hip resurfacing on higher risk patients, their overall results will improve. I disagree with this defeatist strategy.
My improving results are not achieved by patient selection. I have always
practiced minimal patient selection and my criteria have not changed much over the last 10 years. Instead, my goal is to find treatment modifications to improve the results in patients that are traditionally identified as higher risk. In some cases, we have already accumulated scientific evidence of improved
results; in other cases, we still need more time to gather data to be certain that our treatment modifications have improved results. Examples of our innovations include:
1. Femoral neck fracture: stratifying risk of femoral neck fracture by bone density and BMI and treating higher risk patients with slower weight bearing and bisphosphonate drugs. We have demonstrated that this substantially reduces risk.
2. Failure of acetabular implant attachment: dysplasia patients
are at higher risk because of socket deformities. Use of Trispike acetabular components in severely deficient sockets has eliminated these failures in this high‐risk group.
3. Femoral cysts: Bone grafting cysts instead of filling them with cement has resulted in eliminating femoral cysts as a risk factor for failure in our patients.
4. Femoral Loosening: The major source of late failure in my cemented femoral components. We have demonstrated that uncemented femoral components are equally as good as cemented ones at up to four years follow‐up. Our hypothesis is that uncemented femoral components will be less likely to loosen in the long term.
5. Adverse wear failure: This has been linked to acetabular component position, particularly high inclination angles (AIA). We have developed an intraoperative XR technique that has lowered the chance of implanting a component with an AIA>50 from 26% to 4%. Recent improvements in our technique are focused on still further improvements in the odds of achieving ideal component position.
I have been performing hip resurfacing for over 10 years and have maintained an accurate database of current patients with an overall >90% rate of follow‐up. This chart presents the results for 2480 cases.
Updated August 2011
Dr. Gross 2011 Summary of Outcomes for 2500 Hip Resurfacings
procedures over the last 12 years. Most failures occur during the first 6 months of the healing period. However, there is a slow rate of failure that occurs over time. Therefore the overall failure rate increases for a group of patients as the length of follow-up increases. In our recent publication in the Journal of Arthroplasty 2011, we reported that our Corin Hybrid HSR achieved a 93% survivorship at 11 years follow-up. Longer-term data is not available. Multiple improvements have been made since this initial patient group. Our most recent cases use the Biomet uncemented Recap /Magnum. We report here the early results of the first 1000 done between March 2007 and July 2010 with a 99.4% rate of follow-up (90% completely up to date on their follow-up, and 64 % achieving at least 2 years
follow-up). Not all complications lead to failure. Below is a complete list ofmajor complications (not just failures) in the first 1000 uncemented HSR using the Biomet system:
A.) Failures Requiring Revision Surgery (1000 cases):
1. Femoral neck fracture: 62. Early femoral collapse (avascular necrosis): 23. Failure of acetabular ingrowth: 54. Adverse wear failure: 25. Deep infection with loss of implant: 06. Recurrent dislocations requiring revision: 07. Femoral component loosening: 0
8. Acetabular component loosening 0
9. Subtrochanteric femur fracture 1
(related to hardware removal)
TOTAL: 16 1.6%
B.) Cases requiring significant repeat surgery (1000 cases):
1. Traumatic intertrochanteric fracture 2
(5 and 11 months postop):
2. Deep infection (cured): 2
2. Significant superficial infection (cured): 1
3. Frostbite from ice machine: 2
TOTAL: 7 0.7%
C) Other Complications (1000 cases):
1. Dislocations: 2
2. Pulmonary emboli: 3
3. Deep vein thrombosis: 2
4. GI bleed requiring transfusion: 1
5. Minor stroke: 1
4. Nerve injuries: 0
5. Postoperative transfusions: 0
6. Femoral notches: 0
7. Vascular injuries: 0
8. Deaths: 0
TOTAL: 9 0.9%
a title=”Dr. Gross Chat Questions and Answers on Nov. 11, 2008″ href=”https://www.surfacehippy.info/grosschat1108.php”>
Dr. Gross Chat Room Questions & Answers on Nov. 11, 2008
Dr. Gross Chat Room Questions & Answers on Sept. 30, 2008
A Seven-Year Follow-up Study Metal-on-Metal Hip Resurfacing with an
Uncemented Femoral Component Sept. 2008
Between 1999 and 2000, eighteen patients (twenty hips) underwent primary
metal-on-metal hip resurfacing with uncemented femoral and acetabular
components. One patient was lost to follow-up. This left eleven men and six
women, who had a mean age of forty-five years at the time of surgery. Clinical
and radiographic examinations were performed prospectively, and the results were
How many surgeries do you feel doctor needs to do
to be proficient?
100 HSR would be a good benchmark.
Several US surgeons allow all
activities after 6 mos. What are your guidelines?
I allow virtually all activities at 6
Does the insertion of the acetabular component
require more bone removal in a resurfacing procedure as opposed to a THR.
I do both procedures and remove the same
amount of bone on the acetabular side whether it is a HSR or THR.
Do you prescribe Physical Therapy post op. Can you explain why?
With the minimally invasive posterior
approach no formal physical therapy is necessary. I think it can be counter
productive in the first 6 weeks, after 6 weeks I am happy to prescribe this.
What is your opinion about running and jogging after
I do not recommend marathon
running but light jogging is permitted.
What is the difference between the Biomet device and
the BHR device?
I designed the Biomet
device and feel the instrumentation makes it easier for the surgeon to implant
because of their accuracy. Implants are thinner and require less bone removal.
Biomet was the first to offer 2mm sizing with 12 implant choices, now it is the
only one currently available with an uncemented component in the US.
What anesthesia do you normally prefer?
I recommend spinal
anesthesia with sedation plus multiple pre-emptive anti-nausea medications.
What Blood thinning method do you prefer?
Blood thinning is highly
controversial, there are many acceptable alternatives. My preference is 10 days
of Arixtra followed by one month of 81 mg aspirin. My DVT rate is less than 1%
with no pulmonary embolism in 1500 cases.
How long before complete bone in growth has occured for
the socket component?
I estimate the process is 90%
complete at 6 months and 100% complete at 1 year post op.
Do you suggest Fosamax to increase bone density
There is good basic science
data in animals that Fosamax increases bone deposition around uncemented
implants. Therefore, I recommend it in osteopenic patients.
What the safe levels of chromium and cobalt ions after
No one knows what safe levels are. These are normal elements in
our body. They are elevated after placing metal implants. There is no value to
measuring and following levels at this point.
types of daily exercise do you suggest?
At 2 years virtually all exercise is good
except possibly extreme repetitive impact sports such as marathon running. No
one knows for sure.
Is recovery from a hip resurfacing slower than recovery for a THR?
The recovery is identical. I would recommend waiting 6 months to return to
vigorous activity. I perform both resurfacing and THRs.
and type of activity is helpful in the initial week after surgery? Is
Walking is a great
exercise for the hip, you should gradually be able to walk longer distances
outside, I would be very careful with stretching, hip range of motion will
return to normal with or without stretching.
How soon after resurfacing can one start stretching to regain
ROM? Do you
recommend any type of physical therapy?
You may start stretching at 6 weeks, but no extreme flexion
exercises for at least 6 months. Physical therapy is not required after a
posterior approach, the muscles recover quickly with walking and a simple home
What activity should I be doing during the first week post op hip resurfacing
You should be
up out of bed, walking around in your house, and sitting in a chair most of the day.
Walking outside for one to two blocks a day is a good idea. You can gradually
progress your walking from there. You should also ice and