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Author Topic: HSS/Cleveland vs Mayo/Harvard?  (Read 1130 times)

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ricol

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HSS/Cleveland vs Mayo/Harvard?
« on: July 01, 2018, 02:45:26 AM »
Hi everyone,
I'm an active 42 yo male, and have severe OA in my hip. I'm scheduled for resurfacing surgery with Dr. Su at HSS this summer, and I've gotten a little spooked by all of the 2011/12 press in the NY Times etc. about metal risks, and I am also concerned that there is still relatively short follow-up in large studies of cancer risk, although available data so far is reassuring. 

I immediately felt comfortable with Dr. Su and trust him and his team a lot, but I have also inquired about a second opinion at some other hospitals. I have not seen another doctor yet, and may not, but this is what I learned by phone:

HSS (Su) and Cleveland Clinic (Brooks) do
resurfacing; Mayo Clinic used to do them, but no longer does, and in fact warns against them, and Mass General/Harvard doesn't do them and never has, citing "high rates of early revision."

My question, and concern, is why would these four elite orthopedics departments disagree fundamentally about this procedure? Also, what Mass General told me about early revisions certainly doesn't match what Dr. Su's PA told me about his 98% success rate at 15 years.

Thoughts and perspectives much appreciated!

« Last Edit: July 01, 2018, 03:08:08 AM by ricol »

Pat Walter

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #1 on: July 01, 2018, 01:52:03 PM »
Hi  Welcome to Hip Talk.

Hip Resurfacing is a very special method of replacing a hip.  Ever since I began this website in 2005, hip resurfacing has never been widely accepted by the medical community.  There might be several reasons for that.  One is that hemi-resurfacing which only replaced the femoral portion of the device had very poor success.  When full hip resurfacing began, the situation was now metal on metal bearings, not metal on bone bearing surface.  So once a procedure received poor outcomes and bad press - it never goes away, even when it isn't the same as the similarly named option.
So many surgeons remember hemi-resurfacing and remember how poorly it worked.  http://surfacehippy.info/category/hip-resurfacing/hr-vs-hemi-resurfacing/

Also hip resurfacing requires more training than a THR and many surgeons chose not to learn it or find it difficult to perform.  That is another reason why hip resurfacing received a bad rap - too many non experienced surgeons jumped in and performed a large amount of poor surgeries with very poor outcomes.  One big study that indicated hip resurfacing had bad outcomes was from a group of 20 interns that were taught hip resurfacing and performed them - poorly.  That was in the UK and that study continues to plague hip resurfacing with a really bad name.  Really, how can inexperienced surgeons expect to have the outcomes of experienced surgeons who have done thousands. Once the news media reports poor outcomes for a procedure, they never seem to forget and continue to bad mouth it since negative news is always more sensational than positive news.

Hip resurfacing is almost an art as much as a skill.  Just like an athlete, if the pitcher doesn't practice every day - he becomes rusty.  So with difficult surgery.  A surgeon that has excellent results must perform hip resurfacing every day, every week and every month.  They must be specialized in hip resurfacing to have excellent outcomes.  The surgeons on this list are very experienced:  http://surfacehippy.info/doctors-with-1000-hip-resurfacings/

Also if you want to know about the great outcomes of hip resurfacing, you need to talk to and read about the results of the top surgeons. You can't rely on the negative press that attacks hip resurfacing over and over again.  Here are excellent articles from the top surgeons:  http://surfacehippy.info/category/hip-resurfacing-positive-results-and-information/

When you want something special, you must find a specialist.  You don't go to Wal-Mart to buy a Smith & Nephew BHR.  You go to a specialist in hip resurfacing to receive a BHR.  You don't go to the local flea market to buy a sophisticated piece of equipment. You need to decide where to acquire professional, high end equipment or hip resurfacing surgeries.

There are over 1420 personal hip resurfacing stories posted here by the members:  http://surfacehippy.info/category/hip-stories/ 


Also thousands of posts from hip resurfacing patients on this discussion group of 5000 folks.

If you want to find out about hip resurfacing, you need to talk with the top experienced surgeons and the patients that have had a hip resurfacing.  Yes, there are occasional problems, but there are very few.  There are always a small amount of problems with any surgery, or any vehicle or product you buy - but you can't do nothing or buy nothing thinking you will have problems.  That is life, we choose what we think is the best for us and know we have done our homework.  Sometimes there are problems, but not normally.  Sometimes the jet plane you are riding on will crash - but not very often.  Sometimes the car you are riding in will crash - but not very often.  Sometimes your house will burn down - but not very often.

We always need to do our homework and learn as much as possible, then make an educated decision.  Hip resurfacing has been chosen by hundreds of thousands of people who had excellent outcomes.
I am sure others will give you some input here, too.
I wish you the best of luck.
« Last Edit: July 01, 2018, 01:54:15 PM by Pat Walter »
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blinky

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #2 on: July 01, 2018, 03:46:33 PM »
American medicine is decentralized. Yes, some doctors monitor their results and even publish them, but most don't. Yes, most doctors take some CME and stay up to date, but honestly, others find procedures they like and are comfortable doing and just stick with them. I think that's why you find such different opinions.


I am from a place where no one does resurfacing any more. I got some opinions from the resurf doctors Pat lists who told me to go for it, then talked to a slew of respected local guys who all said don't do it. (Okay, except for one guy, who conceded that he had recently gone to a big ortho conference and met this guy from North (sic) Carolina who had great results with resurfacing.)


Sure, it gave me pause that my personal first choice was so controversial, but I was comforted by two things: 1) the docs I liked had published, peer reviewed results. The one I chose, Dr Gross, attended, no led, discussions at big ortho conferences where he openly advocated for resurfacing. People respected him and his results. He wasn't some crackpot. 2) I was having my surgery in 2015. In around 2012, there were some big papers published about how to best install the ace tabular cup, the best angle to put it in to avoid the metal ions issue. I felt like, yes, there had been some issues with metal hip resurfacing devices, but the major issues had been resolved so I had stood a strong chance of a great result. (There had also been a defective device that was withdrawn from the market before 2015. The fact that there had been a defective device, though, tainted what people thought about all resurfacing devices.)


Having said all that, the choice is yours. No doctor has a 100% success rate. Pick what you are most comfortable with.

John C

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #3 on: July 01, 2018, 04:36:29 PM »
Hi ricol, welcome to the forum. Pat did an outstanding job of addressing your concerns, and in fact I hope she saves her post somewhere as a great reference. I will just add a brief reinforcement of what she said. Here are a few thoughts that were key for my own evaluation.
1, In any profession or skill, there will be a large number of people who are competent at basic tasks, and just a few who are expert at very difficult specialized tasks. If you look at the results of the average practitioner attempting the very specialized tasks, you will come away with the conclusion that the specialized task has a low success rate. This information is only relevant if you intend to have the average practitioner perform the specialized task. Only by isolating your study to the performance of the few experts in the field will you come up with a realistic view of the potential of the task.
2. Resurfacing is a challenging surgery that has a learning curve, meaning that even a very talented surgeon may have a poorer success rate for his first few hundred surgeries. This presents a tough barrier for any surgeon to decide if going through that learning curve for himself and his patients is worth it in the long run. It would only make sense for those in a position to be able to plan on doing a high volume of resurfacings in the long run. I have talked this over with orthopedic surgeons who are friends as well as with other surgeons who I respect, and most of them do not do resurfacings for this reason; they never expect to do enough of them to justify the learning curve and to be able to keep their skills honed. Some surgeons will blame the procedure as being flawed, rather than acknowledging that it is too specialized to fit into their practice. In an ideal world, these surgeons would refer potential resurfacing cases to a specialist, but in reality that seldom happens.
3. I applaud your homework in contacting some of the top hospitals with your questions. My view is that the answers you will get will be determined by whether each hospital has a resurfacing specialist on staff, and there are not many of those to go around. If their staff does not include a resurfacing specialist, you will get a negative review from the staff members who do not do them. As far as Mass General's statement about "high rates of early revisions", this statement can only be based on mass studies from the early days of resurfacing when things like femoral neck notching, cup angles, and poor prosthetic designs had not yet been worked out. It is also a certainty that any statistics they quote will be from studies including large numbers of non-specialized surgeons, which as mentioned above are not relevant if you are planning on using a resurfacing specialist, in which case only results from those surgeons are relevant to your study.


I admire you for doing your homework, it is a process that most resurfacing patients have gone through. I think that you have found a great surgeon in Dr Su. If you want to do further research on resurfacing, I would not worry about top overall orthopedic hospitals since that covers a huge field of questionable relevance, but focus your research on top resurfacing surgeons and read through their published results. Then if you want a comparison, compare that to the statistics for those top overall hospitals, but be very certain to match the age and activity levels in the studies you are looking at to your own situation. If you are an athletic 42 year old, most studies involving THRs will not be relevant to your case unless you break the study down to fit your age and activity level, which will likely change the results of the study dramatically. In the end it is a very personal decision that balances tradeoffs, since there is still no perfect risk free solution that can bring us back to a perfect biological hip. Find the option that best suits the balance of risks and rewards for your needs and the demands that you expect to place on it.


John/ Left uncemented Biomet/ Dr Gross/ 6-16-08
Right uncemented Biomet/Dr Gross/ 4/25/18

ricol

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #4 on: July 01, 2018, 07:49:02 PM »
Hi everyone,
Thank you for the welcome Pat and to all of you for your responses. I'm eager to hear more as others share their stories. Very glad to have found this support!


I agree, with a surgeon like Dr. Su, I'm less worried about the early revision risk etc. and am comfortable with his skill and experience.


My greatest concern, I don't think can really be put to rest with currently available data: which is that follow-up studies assessing cancer and other health risks are more or less a maximum of 15 years long (seemingly not long enough to ease the collective worry in the medical community about metal ions). If there were 30 years follow-up, it would be much easier to make definitive statements about the degree of risk, and perhaps more widespread acceptance would follow. But of course there's no short-cut to 30 years follow-up!


John, from your picture, it looks like you're an accomplished skier.... Skiing is my sport as well....how are you finding your BHR?


thanks again!

John C

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #5 on: July 01, 2018, 09:57:55 PM »
Hi ricol,
In answer to your first concern about cancer and metal ions, I think that you might be able to locate some of the long term data you are looking for. While the data on metal on metal resurfacings only goes out about 20 years, I believe that you can find data on metal on metal THRs going out 30+ years as you were hoping. Its been a long time since I looked this up, but I believe there was a long term Swedish study that showed no cancer risk, and overall life expectancy was slightly better than the norm, I am guessing due to higher activity levels. You might also take a look at some of Dr Pritchett's publications. He was around for the first versions of resurfacing back in the 1970s, most of which failed due to the unexpected wear rate of the poly liners. However, there were a few metal and metal resurfacings done back at that time that had good survival rates for the time, and I believe that these might be a source of confirming no cancer correlation over 30+ year periods. The bottom line is that I think that you will find the 30 year MoM data you are looking for if you include MoM THRs and those very early MoM resurfacings in your search.


As for your question about my experience with skiing, I am almost reluctant to post it again because some of the other people on this site have read about it so many times before, but I guess they can just skip this part. If you want a blow by blow description of my experience, I am sure that you can easily find a lot of my older post on this site going back 10 years.
Here is a synopsis. I have been teaching skiing full time (7 hours a day, 7 days a week) in Sun Valley for 48 years, and before that was a racer, freestyle competitor winning a couple of mogul and aerial titles, and film stunt skier appearing in half a dozen ski films. My left hip starting going bad when I was in my 30s, and I put up with the pain and limping until I had it resurfaced by Dr Gross 10 years ago when I was 56. Note that mine is not actually a BHR which is a brand name that Dr Su and many others use, but Dr Gross does not. My resurfacings are both Biomet cementless. Dr Gross allows skiing at six months which put me in mid November. I hiked up the mountain to ski at exactly the six month mark, since the lifts were not yet open for the season. When the lifts did open a few days later, I spent the first hour on the beginner chair to test things out, and then went straight to skiing powder and crud for the rest of the day with no issues. I was a little stiff and sore after skiing for that first few weeks, but on the hill things felt pretty good. I did not start skiing bumps aggressively until about 8 months out, and that went fine. I laying carved trenches on the groomers right from day one, but held off on gates until 8 months just to be safe. Ever since the surgery, I have been very conservative about jumping onto a hard landing, though I am still comfortable dropping small cliffs and cornice drops into powder landings. I finished that first season with a heli trip up to Canada, which I usually do in December, but waited until April that year.
Challenges: I would say that it took about a year to feel totally confident doing one legged exercises like Javelin turns, White Pass turns, Stork turns, etc; no real problems, just some weak glute med and min, as well as rotators. I would say that the hardest thing to get back has been skating. It was definitely uncomfortable for the first three or four years. The pain has gone, but my skating still feels weak, especially skating uphill.
Bottom line; after 10 years on my first resurfacing, I certainly cannot ski like I am 20 or 30, but I would say that it does allow me to ski very strong and aggressively for a 66 year old; on piste, off piste, heli, etc. Next season I am expecting that my second resurfacing that I had done two months ago will allow me to ski even stronger than last year, with less pain and better range of motion.


For what its worth, I have students, as well as fellow coaches, who ski a lot on both resurfacings and THRs. I have found that the skiers I know on resurfacings tend to ski with less concern about any restrictions, but that could be psychological, or due to their doctors advice. I have seen a few cases of THRs dislocating when people bent over to buckle their boots at odd angles, but I think most of those were with the old 28mm heads that were so prone to dislocate. A couple of the strongest skiers I know on THRs had to have them revised after about 15 years, but that was with the older poly liners, so a tough comparison. I have also seen a couple of cases of periprosthetic fractures in skiers with THRs, which I have never seen with a resurfacing. That would be one my biggest concerns, since my non-medical understanding is that stress shielding in THRs often leads to a decrease in bone density in the femur, whereas studies I have read show an increase in bone density with a resurfacing. I have landed hard on mine on ice at 45 mph, with no problems whatsoever.


Standard caveat; this is all just one persons experience, full of non-medically trained opinions, so your mileage may vary. Best of luck in your process.

John/ Left uncemented Biomet/ Dr Gross/ 6-16-08
Right uncemented Biomet/Dr Gross/ 4/25/18

Saf57

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #6 on: July 02, 2018, 03:40:08 PM »
I have had both hips successfully resurfaced, one in 2003, the other in 2015. Resurfacings now comprise well less than one percent of the hip replacements performed in this country. Yet, for the few surgeons that do the procedure, the success rates are exemplary. And, there is no question that for the active patient, resurfacing provides better outcomes. So, we should ask ourselves--why is that? Why do the top hospitals and the top orthos nearly universally shun the procedure?

John C

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #7 on: July 02, 2018, 10:10:14 PM »
I will offer a theory in answer to Saf57's very valid question; lawsuits. The only thing that many people have heard or read about resurfacing are the ads they may have seen on TV, online, or in magazines from lawyers advertising for people to become involved in resurfacing lawsuits. What doctor in his right mind, unless they are very dedicated to the concept, is going to take on a surgery that has notable talk about lawsuits? It is another discussion as to how many of these lawsuits are valid, and whether it is good or bad for a society to be as litigious as ours, but the fact is that having ads out there promoting lawsuits against a procedure like resurfacing must be terrifying to doctors and hospitals, not to mention the manufacturers. From my point of view, some of the information offered on the web sites advertising for these lawsuits is questionable as to its detail or accuracy, but unless a person has done enough of their own research to read between the lines, the information presented sounds pretty scary.
I do not think that many doctors are ever free from the fear of lawsuits, especially the unjustified ones. In order to become involved in a medical procedure that already has lawsuits attacking it, and lawyers actively advertising and promoting those lawsuits, a surgeon or hospital would have to be not only brave, but supremely confident in their skills and the data to back up their actions. This should make us all doubly grateful for the skilled and courageous resurfacing surgeons who are willing to stand up with their data for something that they, and we, believe in.
So, in short, the answer to Saf57's question may be that in this case medical treatment is possibly being dictated by fear of unjustified lawsuits, as well as public opinion based on quasi informed media reports. Sad, but possibly true.
John/ Left uncemented Biomet/ Dr Gross/ 6-16-08
Right uncemented Biomet/Dr Gross/ 4/25/18

Saf57

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #8 on: July 03, 2018, 03:34:31 PM »
I will say(and I am an attorney myself) that the issue raised by John C. may be a factor, but I believe a modest one. All doctors and hospitals manage the risk of malpractice suits through the use of insurance and other techniques. Hospitals are sued every day. The orthopedic community is generally conservative, and slow to change. THR surgeries produce huge revenues for the manufacturers, hospitals and doctors. While it is a good surgery that has helped many people, it pains me that it, and not resurfacing, is considered the gold standard for those, like most of us here, afflicted with arthritic hips. And we cannot deny that the profit motive plays a role in this state of affairs.
« Last Edit: July 03, 2018, 03:51:05 PM by Saf57 »

Joe_CA

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #9 on: July 03, 2018, 07:39:36 PM »
Saf57 poses a very interesting question. John C's lawsuit explanation as a considerable factor has merit in my opinion, given the stigma of the "troubled times" roughly 8-10 years ago, when lawyer advertisements were saturating the media. I still recall some of the commercials, and I was asking myself "who in their right mind would choose to get a metal-on-metal device?" At that time, I had no true understanding of hip resurfacing, and the reason patients sought out the specialized procedure. I'm guessing that not only are practitioners wary of taking years of extra time to learn a discipline which even today has the remnants of bad press (slowly this is changing), but they're also being halted by bureaucratic decisions and policies made by executives at the HMOs and hospitals they work for.

If I had to guess the one largest factor in relatively low rates of this wonderful procedure, it's the lack of demand. I'm not quite sure hip resurfacing is necessarily being shunned widespread by the medical community. Part of this is due to the relative obscurity of this procedure even today (thank heavens for this website). 95%+ of the people I run into have never heard of hip resurfacing. If anyone recalls my story (and many similar stories from others here), I actually ran into a sports medicine MD who apparently had little understanding of HRA.

IMHO the biggest factor influencing the low demand, at least for now, is purely statistics. I believe most of us here are somewhat of a select group. What percentage of adults in America run 10Ks, mountain bike 75 miles per week, practice competitive martial arts and who are also typically, at a minimum, in their late 40s years/early 50s? Then reduce that number by those of us unfortunates who have bad hip(s) and who are still motivated enough to go through a less-known procedure. I bet many simply packed it in when they hit middle age, being content with the good athletic years they had (which is totally fine).

Perhaps someday, when the other benefits of hip resurfacing (e.g. longevity etc.) become more apparent to the public, the procedure's popularity will increase. But I'm still speculating that it will never come close to the level of total hip replacements, which is unfortunate...
« Last Edit: July 03, 2018, 07:49:03 PM by Joe_CA »
Bilateral patient
Dr. Gross
December 12, 14 2016
Biomet (uncemented)

Saf57

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Re: HSS/Cleveland vs Mayo/Harvard?
« Reply #10 on: July 03, 2018, 09:30:47 PM »
Joe, that is a very cogent post. However, it is the medical community that drives the demand. Hip resurfacing is on the wane because it is not presented as an option by the orthopedic community, whether you are an athlete or not, as your own experience(and, really, all of ours) demonstrates. The number of THR's has increased dramatically in the last few years, with a lot of the increase among younger, more active people whose hips are shot, and are being sold THRs. That, in my opinion, is a terrible disservice by the medical community to their patients. The fact that a prospective candidate has to, more often than not, stumble upon a site like this to discover that there is even an alternative to a THR is sad. Pat, and a few others, deserve kudos for their work, but face an uphill battle. Hopefully, the few surgeons who perform resurfacing will train their successors, because it is difficult to imagine that the remaining 99+ % of the orthos/hospitals will ever come around, or even offer resurfacing as a viable option, given how easy it is to generate $$ by performing THRs.
« Last Edit: July 03, 2018, 09:56:00 PM by Saf57 »

 

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