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LOGAN13

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Surgical Alignment guide
« on: December 01, 2009, 12:48:37 AM »
I received a letter from the hospital in which I will soon be having my hip resurfaced. The letter invites me to participate in a research study. My surgeon is conducting a  study on a new type of surgical alignment guide that is referred to as the Visionaire Femoral Alignment guide. The alignment guide is used to assist the surgeon in finding the center of your femoral neck to allow accurate placement and alignment of the BHR

I was wondering if anyone(especially Pat) has any information/knowledge of this technique.

Also, in the risk/benefit paragraph there was a sentence that was unsettling. It reads "We expect the overall risk of cancer to be less than 1 in 3000, due to the hip CT scan.  :o ???

Thanks Tim


Pat Walter

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Re: Surgical Alignment guide
« Reply #1 on: December 01, 2009, 01:36:26 AM »
Hi Tim

I can tell you that most of the really experienced hip resurfacing surgeons don't use computer assisted surgery.  All of them claim they have tried it and their placement of the acetabular cup and femoral component is more accurate that that done with computer placement.  Computer assisted surgery is designed for the less experienced surgeons who need help in getting their placement done properly.  The problem, as I listened to the discussions in Sept. in Baltimore at the 3rd annual hip resurfacing course, is to get the computer program set up properly within the hip. It takes all kinds of time and alignment to get everything in place to use the computer program - as I understand it.

So a lot depends on the expeirnced of your surgeon.  I don't know who you are using, but I do know that he/she is not probably on my list of surgeons that have done 500+ or 1000+ surgerys.  Most of those doctors do not use computer assisted surgery.

A lot depends on how you feel about your surgeon.  If you don't think their skill is great enough to place the components properly, then use the computer assisted surgery.  I personally would prefer to use a surgeon that has a great deal of experience and does not use computer assisted surgery.  Many people, however, do not want to use those surgeons so the CAS does help with a better placement of the device.

Of all the discussions I have heard at the course for hip resurfacing, the one thing that has never been much discussed is that hip resurfacing causes cancer.  In fact there was an obscure medical study that showed hip resurfacing patients have less cancer than regular patients.  The doctors suggested that hip resurfacing patients on the whole were much more active and most likely in better shape than many other people.

I will say that there is much more interest about placing the femoral component in the center of the femur neck rather than the femur ball.  All of this is based on experienced.  The trend has changed since resurfacing has started. Just as the angle of the acetabular cup is now considered very critical.

I can only say that each patient has to choose a surgeon which in turn choses a surgical approach, device and other options for their patient.  If you don't like what they are choosing, then consider getting several other opinions.  You only have 2 hips and you need them both in excellent shape to walk properly for the rest of your life.  There is not much room for error in hip surgery. Listen to that voice inside - if it says there are many questions, look further.  If it says this is the doctor for me - then go with it.

Pat
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bothdone

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Re: Surgical Alignment guide
« Reply #2 on: December 01, 2009, 09:48:52 AM »
Hi Pat

Can I just congratulate you on the post above.    You've neatly summed up the whole choice of surgeon with your sentence "Listen to that voice inside".    

I'd just like to add a few thoughts from a different perspective but in keeping with your "voice inside".

I had my first BHR in May 2004.   I considered various options and decided that I wanted to be as local as possible, but with a surgeon I trusted.     The consultant I'd been seeing on the NHS was someone I felt I could trust and I opted to pay for private treatment with him.

At the time I think I was about BHR number 44 for him.   To be absolutely honest the low number didn't concern me.  From talking with him I could feel his passion for doing the job well and getting things right for me.    I went back to him for my second BHR in March 2008, this time on the NHS.     I am very happy with both hips.

For anyone concerned about talk about placement angles and sizes of components let me add a few more thoughts.  I have no idea about any of those things inside me.     At the time of my ops I wasn't aware of anything to do with them.   I placed myself in the hands of the surgeon, much as I place my car in the hands of a garage I trust.    I discovered this site well after my second BHR.     Would I ask about them now, having read about things on here?    Most likely I would.   As Pat says, your decision will affect your life afterwards.  It needs careful thought.

Thanks again, Pat.

Ed
« Last Edit: December 01, 2009, 09:50:24 AM by bothdone »
LBHR 25 May 2004
RBHR 19 March 2008

Pat Walter

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Re: Surgical Alignment guide
« Reply #3 on: December 01, 2009, 12:49:34 PM »
Hi Ed

Thanks for your thoughts about doctor choice. You are correct in the thought that a person should select a surgeon they trust and the surgeon will select the surgical approach, device and post op protocol that best matches the patient's needs.  As normal people that are not medically trained, we have no way of making the technical selections other than the surgeon.  We can read all we can, but there is a point that we must trust the surgeon.  It is like getting on that big jet plane - we must trust the pilots to keep us safe. No matter how much we know about flying, the plane is not in our hands.

I do talk a lot about trying to choose a surgeon with a lot of experience.  That is based on medical studies, doctor discussions and reading thousands and thousands of stories over the last 5 years.  The retention rate before 2006 for the BHR overseas was 99.9% according to studies.  Then when the US doctors started doing the BHR in 2006, it dropped to 96%   So that means that the newer surgeons were having some problems.  If a patient wanted to be pretty assured of no problems, it makes sense to use the expeirnced surgeons and be one of the 96 people out of 100 in the US that did not have problems.  Unfortunately, the 4 people out of 100 that had problems resulted in serious problems like revisions to THR.  So I try to influence people to use the most expeinced surgeons where ever they live.

It does not mean that a person using the less expiernced surgeon will have problems, there are many cases of people using the new surgeons that did not have probelms.  I, however, have a huge file of emails from people that did have problems.  Misplaced cups are the most common problem.  So it is a real problem according to medical studies, national registries and my own expeirnce in talking with people with problems.

So I make suggestions and then tell people there is a time to make a choice.  Listen to your gut feeling.  It is the best advice you can get after doing your homework and meeting the surgeon or surgeons of your choice.  A little prayer never helps either.

As I mentioned, this is such major surgery and you only have 2 hips.  Once they are done incorrectly, it is diffiuclt to get them revised proplery so you can be out of pain and be active again.  I have emails from people that are on their 2nd and 3rd revisions and still don't have it right.  So there are a few horror stories out there, but they are in the very, very minority. Thank Goodness!

So read, learn, talk and then listen to your "little voice inside."

Pat
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3/15/06 LBHR De Smet

stevel

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Re: Surgical Alignment guide
« Reply #4 on: December 01, 2009, 04:04:33 PM »
An inner voice that steered me to Dr. Su above all others in the US, was Vicky Marlow.
Some patients have chosen Dr. Boettner and Dr. Mayman at the HSS and even though they have done fewer surgeries.

Long term success of a hip resurfacing is more than the Dr.  It's also the device.  Compare the results in Australia and the BHR is the best.
Conserve Plus was just approved by the FDA in the US, but hasn't done as well in Australia.  Neither has Biomet, which isn't approved yet in the US, including the uncemented version currently being installed by Dr. Gross.

Short term/long term success of a hip resurfacing is more than the Dr.  It's also infections or lack of infections.  The HSS had only 3 infections per 3600 + or - hip replacements in 2008 and received special recognition by the State of New York, Dept. of Health.  Check out the data at www.hss.edu.

I suppose if everybody went to Dr. Su at the HSS and had a BHR installed, this website would be very quiet with regard to complications, and Pat wouldn't have anything do say, except meet me for refreshments at a gathering for successful BHR hip resurfacing patients.


Steve
LBHR 60mm/54mm Dr Su 9/29/08 age 55
RBHR 60mm/54mm Dr Su 11/1/19 age 66

Pat Walter

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Re: Surgical Alignment guide
« Reply #5 on: December 01, 2009, 04:42:55 PM »
Hi Stevel

Where do you want to meet for refreshments?

Pat
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toby

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Re: Surgical Alignment guide
« Reply #6 on: December 02, 2009, 12:10:04 AM »
Hi Tim, Pat, Ed, Steve et al
Just interested (as a prospecive resurfacer) to learn about several of the issues arising from Tim's posting.
The unsettling sentence re- cancer is a little puzzling and worrying! 
The topic of navigated surgery is a mine field!
And finally I want to learn more/have a "little" question  about the issue of devices, raised by Steve.
So firstly, in Tim's posting-re- the risk/benefit paragraph there was a sentence that was unsettling. It reads "We expect the overall risk of cancer to be less than 1 in 3000, due to the hip CT scan".
 It's the term 'due to' which is confusing. Is the suggestion that the CT Hip scan leaves one/places one at risk of a  1 in 3000 chance? or is suggesting that your particular scan results show you to be at a 1 in 3000 risk category? How did you read it Tim? And who is the surgeon and how many HR's?
Linked to this my Second point of interest  Pat is the topic of Computer Assistance. From what I've researched some surgeons in the UK (and I remember an interview on surface hippy with an experienced US surgeon who felt that if it were widely introduced in the US it would bring benefits) who are reasonably experienced 250 plus feel that the Computer assisted/navagational approach(to both plan the surgery and during the operation) combined with their experience can deliver superbly precise component positioning. Pat, I hear what you say about those surgeons who suggest that it takes time to set up the computer system and they don't need it etc but is there an issue here about not wanting to change or is genuinely that their precision is better without?  How widely available is the technology in the US?  Maybe there's great results to be had from both approaches and those trained to use the hi tech operational technique always will. Is the now accepted and wide spread use of key hole surgery an analogy? Surgical techniques have certainly become more hi tech in other areas also. Maybe this is the future for the younger surgeons!
Finally,I know that the BHR is the most widely used and has the largest clinical data-but is it still the best? If it is and leaving aside uncemented-why are some surgeons taking risks with less effective devices?
Thanks and huge appreciation for such a rich and informative asset.
Toby
ps Ed who did your surgery in the UK?

LHR Adept-Prof Cobb-30-1-10

LOGAN13

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Re: Surgical Alignment guide
« Reply #7 on: December 02, 2009, 12:54:01 AM »
Thank you all for your posts.

First I wish to ask Pat..Is the Visionaire Alignment guide mentioned a computer assist to my surgeon, because as I read the letter it tells me that if I choose not to be a part of the study my surgery will be done using the current methods of computer navigation or by using a jig.  ??? Secondly Pat, Here in Ontario, Canada I have found few really experienced surgeons to choose from (those with your sites standard of 100+). Due to Insurance reasons Ontario is where I personally must get my BHR. I have used the site to learn and digest the many many stories, wondering if I will be able  to one day post my happy ending. I have turned down surgeons because of that inner voice you speak of. I cannot put this off forever...I want to move on and enjoy life. What technique are the most experienced surgeons using?

Secondly, I do not wish to alarm anyone by mentioning Cancer. I just had to ask the pros(all you hippies)....does it make sense that a CT scan is a risk. Let me explain exactly what the letter said word for word ...

"There are no additional risks to the surgery noted, other than one CT scan done before the surgery, One CT scan carries the equivalent radiation (3 milli SV) that a person would expect to receive from the enviroment in a period of one year. We expect an overall risk of cancer to be less than 1 in 3000, due to the hip CT scan"


The word cancer is unsettling ....not in any way related to a BHR surgery.I want to make that clear.

Thanks

Tim



Pat Walter

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Re: Surgical Alignment guide
« Reply #8 on: December 02, 2009, 01:11:15 AM »
Hi

I don't know how we got on to the cancer topic.  Hip Resurfacing, according to all I have heard at the hip resurfacing courses does not cause cancer.  In fact it was said those that have a hip resurfacing have a lower rate of cancer.  That was just a discussion I had heard several times.  I saw the stats at the time, but don't have a copy.  There is nothing in a hip resurfacing to cause cancer.  Even metal allergies have not been associated with cancer.  AlVAL and pseudotumors are not cancer. 

I heard McMinn, De Smet, Mont, Gross and others say their placement without computer assistance is far better than with computer assistance.  Plain and simple - their experience is better than computers since it takes a lot of effort and software to set up a computer system for navigating.  If it is not done properly, the placement will not be right.  Dr. Gross talked about how diffiuclt it was to set up these systems.  Others talked about how diffiuclt they are to use and to keep programmed.  They have to be set up for each person's hip since we are all different.  That is all I can tell you.

I would far prefer my hip resurfacing be placed by a very experinced human than a computer.  The reason the CAS is used is to help the less expeirnced hip resurfacing surgeons.  There are a few in the UK that use it because I believe they are helping to develop it.  It is not a bad tool, but that is all it is. There are many types of instruments developed to help install the hip components.  The problem is that the FDA has not approved them in the US.  That is one reason Dr. De Smet likes the Wright since he developed special tools to help assist in the placement. 

Computers are great when they are used for certain reasons.  Resurfacing is something they can assist in, but according to the top surgeons in the world - it can not place the components better than they can by experince. They tried surgery with it and said the placement was not as exact.

Acetabular cup placement is becoming so important as we see so many revisions due to improper angles cuasing high metal ions.  If CAS will help the less expeirnced surgeons, that is good - but remember the most expeirnced surgeons place the cup more precisely than with the CAS.  So who do you want placing your hip device?  A computer that does a good job or an experinced surgeons that does an almost perfect job or perfect in most cases.

I never had a ct scan and never needed one. Most of the really expiernced surgeons require x-rays and many don't even require bone density tests.  They are capable of reading the x-ray to tell your bone density.  So if you surgeon is scheduling a lot of extra tests - ask why.  I don't think a few x-rays will cause cancer.

I don't want this to go into some wild discussion off on a tangent.  Cancer is not a concern with hip resurfacing.  I have never heard any doctor at any course or video interview suggest it was. So lets put that to rest.  I don't want to scare new perspective patients.

They have a great deal to worry about, so lets not add issues that to date have not been a concern.  Proper placement of the acetabular cup is a big concern and that can be solved by using the really experienced surgeons.  If you can't have the best, then I would guess CAS would help.  It is not something that I would want at this point.  I have not been convenienced that it is needed by the top surgeons.  I have the really experinced surgeons on my doctors list.

Pat
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Pat Walter

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Re: Surgical Alignment guide
« Reply #9 on: December 02, 2009, 01:17:29 AM »
Tim

One of the best hip resurfacing surgeons in Canada is Dr. Antoniou.  Many people in Canada use him.  He was at the last hip resurfacing course and unfotunatley, we were going to make a video and ran out of time.  I wish I had since he is so experinced and popular.  Here is his info:

John Antoniou MD, PhD, FRCSC
700 Hip Resurfacings to date***
Jewish General Hospital
Orthopaedic Department, E-003
3755 Cote Sainte Catherine West
Montreal, QC H3T 1E2
Canada
(514) 340-8222  ext.4615
fax: (514) 340-7595
www.shoulderhipknee.com
e-mail:  malevisatos@jgh.mcgill.ca


Dr. Beaule was at the last resurfacing course and is dedicated to resurfacing. I don't know his stats, but here is his info

Dr. Paul Beaulé
Associate Professor, University of Ottawa
Orthopaedic Surgeon, The Ottawa Hospital
Subspecialties:total joint arthroplasty
Tel: (613)737-8899 ext.7-3265
University of Ottawa - Dr. Beaule Webpage

Also Dr. Kim was there 

Paul Kim, MD
Ottawa General Hospital
501 Smyth Rd.
Ottawa, ON
K1H 8L6
613-737-8774

The reason I mention the surgeons that attend is that they are dedicated enough to take time to travel to the US and spend several days to learn as much as possible.  They interact and teach each other also.  So I really think a lot of the surgeons that attend the courses.

Pat
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LOGAN13

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Re: Surgical Alignment guide
« Reply #10 on: December 03, 2009, 11:21:17 AM »
Ok...Last question on this topic.

If not computer assisted can I assume all the very experienced surgeons are using a jig for surgery? If I am off on this ...then what are they using?

Thanx

Tim

Pat Walter

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Re: Surgical Alignment guide
« Reply #11 on: December 03, 2009, 12:42:10 PM »
Hi

Why don't you watch the surgery videos? http://www.surfacehippy.info/shvideos/videossurgery.php Dr. Weeden did one just for this website.  They have instruments to make sure they don't knotch the femur neck. You can see that here on the number 2 video - it is not a surgery video http://www.surfacehippy.info/shvideos/videos.php

When they ream the acetabular cup, I haven't seen many instruments.  It seems they just go in with the reamer and begin.  I am sure it is not quite like that - but to the naked, untrained eye it looks much that way. They have already read the x-rays and marked them with the proper angles, but again, a lot of this is skill and experince.  It is more like the best surgeons are artists than skilled technicians.  No two bodies are the same and we all do different activities.  As you start to listen to the surgeons and watch them do the surgeries, they are falling back on a great deal of experience.  I have watched a number of vidoes of surgeries during the hip resurfacing courses.  Each surgeon approaches things differently and in different order.  Each is an indivual artists as far as I am concerned.  When you see a quarterback throw a very diffiuclt pass, a golfer make a diffiuclt shot or an ice skater make a very diffiuclt jump - you know they have done it thousands of times and are blessed with a gift from God - so it is with the great hip resurfacing surgeons.  Experience is the key to a quality hip resurfacing.

Pat
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Excapnal

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Re: Surgical Alignment guide
« Reply #12 on: December 03, 2009, 02:50:59 PM »
Seems to me, from a geometric perspective, that when you are reaming a part-sphere, it will be spherical no matter the angle of approach and when you place the cup it will have freedom to point anywhere in a very large area, so (it seems to me) the reaming would be no big deal, but placing the cup such that it points spot-on at the femur ball is a real big deal.  Again, seems to me...

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Re: Surgical Alignment guide
« Reply #13 on: December 03, 2009, 04:10:22 PM »
Seems to me, from a geometric perspective, that when you are reaming a part-sphere, it will be spherical no matter the angle of approach and when you place the cup it will have freedom to point anywhere in a very large area, so (it seems to me) the reaming would be no big deal, but placing the cup such that it points spot-on at the femur ball is a real big deal.  Again, seems to me...


The depth has to be correct too. I see what your saying but you would think he has to be pretty dang close since the deeper he goes the more the angle of aproach matters.  Too shallow and theres not enough bone to grow onto, too deep and your hope of a sucessfull revision (if needed) is lessened, plus your chance of impingement increases.  I would think he has to be carefull not to wiggle and have an oversized hole as well. And yes I agree placing the cup spot on is a real big deal.

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Re: Surgical Alignment guide
« Reply #14 on: December 03, 2009, 04:23:18 PM »
Hi Excapnal 
 
Every aspect of reaming, drilling and placing components is very, very important.  It must be pricise.  I don't have enough words to write all I have listened to at the hip resurfacing courses and I am not even a doctor or medically trained.

The two bearing surfaces must match correctly and rub as bearing surfaces exactly to provide even wear.  Even the smallest variation can cause additonal wear and high metal ions.  It is very, very technical.  I am a mechanical engineer and still don't understand everything completely.  After all, how could I since I have never performed surgery on a person as these doctors have.

As lay people, we can read and think we "get it" and "understand it all", but trust me - there is no way you can without having the hundreds of hours of experience inside a the bodies of real people.

So let's let the conversation remain that there is no way it can easily be done and easily be understood by most of us. After all, even some of the best orthopedic surgeons can't or won't do the surgery and they have much more experience than we have.

There are hundreds of variables and they are not simple.  So once again, it comes down to trusting the surgeon just as we trust the pilot of the jet plane.  No way we can know it all.  Even the most experienced surgeons are still learning and changing their methods according to De Smet, McMinn, Gross, Mont, etc etc.  If they ever stop learning, then they will not be at the top of their game any more.

Pat
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Excapnal

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Re: Surgical Alignment guide
« Reply #15 on: December 03, 2009, 04:49:18 PM »
Pat - Try to relax here a little bit; all I said was that from a geometric perspective the angle of approach is less critical than a lot of other things going on; a sphere is a sphere.  Didn't mean it didn't have to be in the right place and I didn't mean it didn't have to be the right depth, etc. Just a small point of geometry.

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Re: Surgical Alignment guide
« Reply #16 on: December 03, 2009, 05:20:14 PM »
Hi

I just don't want new people to thing this is a simple surgery and simple devices.

Actually, according to some medical studies going on now and information at the hip resurfacing course, a shpere is not a sphere when certain brands of resurfacing acetabular cups are being pounded into the hip. It is possible for the cup to distort due to it's thickness and does not remain a sphere - thus another possiblity of problems of two bearing surfaces not operating properly together. It presents the possiblity of more areas of higher wear and high metal ions. From holding and inspecting most of the hip resurfacing devices, I was surprised to hear that the acetabular spherical cup could be distorted during the press fit. The BHR is not one of the cups that distort according to the discussion.

Again, it is very complicated and each device is a bit different in design and thickness.  Some of the designs have cups that can cause impingement if not set at the proper depth. The possiblities of problems go on and on and it is not a simple issue of a sphere being a sphere. It only seems simple to us because we don't understand everything that is involved.  It is very technical and I have seen information that even as a person with a mechanical engineering degree - I don't understand since I am not medically trained.
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stevel

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Re: Surgical Alignment guide
« Reply #17 on: December 05, 2009, 12:49:22 AM »
Hi Pat,

How about we meet for refreshments in Freemont, CA on April 17, 2010?  Vicky Marlow is coordinating the event for surfacehippies and newbies and Dr. Su will be there "in person" to review x-rays and answer questions.
Her website has more details.
Steve
LBHR 60mm/54mm Dr Su 9/29/08 age 55
RBHR 60mm/54mm Dr Su 11/1/19 age 66

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Re: Surgical Alignment guide
« Reply #18 on: December 05, 2009, 04:11:13 AM »
Hi Steve

That would be great, but it is a long drive from Southern Ohio.

Her get togethers are great.

Pat
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