Surgeon prefers THR

[Hitman]

I知 a 45 year old male with significant AO in my right hip.  I知 in great shape otherwise.  My orthopedic in PA told me that doctors are starting to back off hip resurfacing a bit now, leaning toward THR, even on younger patients.   He added that with a THR, he can go with an anterior incision, bypassing most of the muscle, reducing the recovery time.  With the BHR, he would use a a posterior incision, cutting thru the muscle and increasing the chance of dislocation and increasing rehab time.  He also stated that with a THR, repairing wear and tear down the road is much easier than converting a BHR to a THR.  Do you agree with this logic?  I was all set on BHR, but now I知 unsure.  Thank you so much for your time.

[Pat Walter]

Hi
I am sure you have read my posts before.  If I did not believe in hip resurfacing, which I received in 2006, and the top resurfacing surgeons did not believe in it - I would not have one of the largest websites about it.  I have a THR website  http://www.hipsforyou.com and I still tell people on that site about resurfacing.

Most surgeons that prefer to do THRs are not as skilled as the top resurfacing surgeons.  The top surgeons that do both will always suggest a resurfacing first if possible.  Resurfacing is very difficult and when surgeons are not skilled they always prefer THRs and badmouth resurfacing.  I am sure you have read the excellent results of resurfacing on the website by reading the medical studies, the national registries and the many hundreds of stories of resurfacing patients. There are also a large number of interviews with hip resurfacing surgeons where they explain why resurfacing is prefered for good candidates.

No matter what the surgeon tell you, he is going to saw off a very large portion of your femur bone and drill a long hole into it.  Drilling out a large part of the femur bone changes the way the bone continues to grow and operate. Dr. Brooks explains this well in his video interveiw  #4  http://www.surfacehippy.info/shvideos/videosdoctor.php   He explains it much better than I could.  So no doctor will convience me it is good to saw off a large portion of my femur bone and pound a long stake into it.

The anterior approach does not mean a faster recovery time.  I have a large incison about 10 inches and I was on one crutch out of the hospital and used it 3-4 weeks.  No pain and nothing but advil leaving the hospital. Walked over a mile a day after 10 days.  Flew 8 1/2 hours home at 9 days post op.  I ate every meal in the resturant in the Holiday Inn and was sight seeing 5 days post op.  The recovery, most often, depends much on the skill of the surgeon - not just the approach.  Some people have slow recoveries, but if you read the thousands of stories I have read - you will see trends of much quicker recoveries generally from the top experinced surgeons.

The anterior approach can cause nerve damage more easily than the postierior approach.  That is why the large majority of doctors use the posterior approach.  It has less chance for nerve damage.  You can read about it here  http://www.surfacehippy.info/faqsurgicalapproach.php 

You are only 45 years old - why go with a THR and have your femur sawed off.  The revision of a hip resurfacing is much easier than revising a THR.  There are people that required revisions and kept their acetabular cups.  They said the surgery was much easier when they were able to keep the cup. 

You don't mention the name of your surgeon.  If he/she has not done a thousand or preferable more, he/she will not give you good input. They will cover themselves and do what they are best at - THRs.  You can choose to go that route, but please read about the types of anterior approach - with or without the table.  Read the problems - they can be very serious. Find out how many resurfacings the surgeon has done not inculding hemi resurfacings.

You have been sold a bill of goods typical to that from inexperineced resurfacing surgeons.  At least go to several of the top surgeons and get input from them. Dr. Gross will give you a free consultation if you send him an email with a copy of your x-rays in a digital format as a .jpg    Dr. Brooks of the Cleveland Clinic is very expeirnced as is Dr. Su of NY.

Get some  input from the top surgeons - then make your decision. If you want a resurfaicng - ask an experinced resurfacing surgeon if you are a candidate. 

Good Luck.

Pat

[Hitman]

Thanks Pat!  Great advice.  I was planning on making an appointment with Dr. Su at HSS.

[andybc]

Pat has summed everything up beautifully. Just to add -a posterior approach for a resurfacing still poses far less risk of dislocation than a thr, however the latter is performed, as I understand it.
I haven't heard it said that "dealing with wear and tear" with a thr is easier than with resurfacing. If "dealing with wear and tear = revision" that is completely wrong.
Glad you're getting another opinion. Although I would opt (and have) for resurfacing, if your 2nd opinion is at variance with the first, I would say get a third then you can be totally confident. (Although, from what I've read, you probably can't get a better opinion than Dr Su).
Good luck.
Andy

[shorelocal]

I had a meeting with a local ortho surgeon today and he also recommends THR over resurfacing.  He mentioned that the reasons for steering clear of resurfacing were the pseudo-tumor issues, the loosening acetabular cups, and the lack of long-term results.  I have to be honest that I was 100% resurfacing until this appointment ... I'm not sure the needle is clearly pointing to resurfacing now.  It leads me to ask, "Why not THR?"

- most resurfacing prosthetics with any history, except the BHR, have been recalled or are no longer for sale
- surgeon skill is VERY important with resurfacing and there are no surgeons local to me performing resurfacing with a BHR
- since no local (ie. in country) surgeons = no insurance coverage = paid for by me personally
- metal-on-metal prosthetics have potential for pseudo-tumor issues

I am a very active individual, but I don't do a lot of running, so the increased wear isn't much of an issue (surgeon tells me that a THR won't restrict my activity level if I'm not a runner).  Also, I understand that any surgeon's advice needs to be taken with a grain of salt, and the surgeon I met with today does not support resurfacing, so he downplays this option.  However, the opposite can also be said of surgeons who specialize in resurfacing touting resurfacing over THR ... they have a vested interest to promote this method because this is their specialty and they are sought after worldwide for these procedures (ie. McMinn, Bose, etc).

I'm really confused and I hope ppl here can help to clear the fog.  Why is resurfacing so much better than a THR, given the facts related to both procedures?

[obxpelican]

Resurfacing can often lead to a result with NO limitations whatsoever, resurfacing allows for a revision to a THR more easily, it also involves the doctor not cutting off a huge chunk of bone off of your femur.

You will have to look this up, but resurfacing allows for a more natural "loading".'

If you get a THR, you will have an acetabular cup installed as well, so that really is a non starter in the debate.

If you get a THR, a revision involves them sometimes cracking your femur to revise which can be a complicated operation.

On the flip side, modern THRs with large MOM heads allow for a fairly natural ROM.

The puesdo tumor happens because the devices are not being installed correctly causing the implants to wear improperly, yes it's an issue if you use an inexperienced doctor.

Hope that helps.

Chuck

[shorelocal]

Thanks Chuck.

I just finished watching Pat's interview with Dr. Brooks where he covers the "loading" topic.  Makes perfect sense to me.

I guess the MoM issue is the same regardless of the type of prosthetic, if I was going to go with a MoM THR, which was suggested as an option since I'm quite active.

As for the revision issue, if the stem is implanted correctly with no issues, hopefully the stem revision is a non-issue (I realize there's always a chance this could happen).  The surgeon I visited with today mentioned that a THR revision for wear issues can be performed quite simply since he would just replace the metal sleeve in the acetabular cup and the ball on the end of the stem.

So much great info available on this site.  I'm now looking up info regarding THR failures in young patients.  Hopefully it doesn't cloud the water even further.

[John C]

Two thoughts:

If you have to have a THR revised, there is a good chance that the femoral stem has loosened. If this has to be revised, it will not be easy, because it has to be somehow extracted from the femur, and this can be tough to do without further damage to the femur. It does not seem that this was well explained in your case.

Regarding the pseudo tumor issue, I would suggest going to Dr Gross's site, and reading his input. My view is that this is not something new. Debris from wear in hips has been the problem all along, with plastic particles historically being the culprit in causing osteolysis; one of the biggest causes of hip failures. There are going to be risk issues with any hip replacement, you just have to decide which ones balance out the best with the benefits.

[obxpelican]

It should be said, that getting a THR is NOT the end of the world, you just lose some options if you have problems.

I might get hung for saying this, but if I had the choice of a surgeon who could do a great job with a THR, I would take that over a doctor who has only done a handful of HRs.  Of course you could end up with a doctor who does a poor job of even doing THRs.

Personally I would still exhaust all options before I got a THR, because once the femoral head is gone it's gone for good.

Chuck

[FlbrkMike]

Dr. Ball, who will be doing my LBHR in February and RBHR in March, does both procedures (BHR and THR).  I was already convinced before I saw him for the first time, about seven weeks ago, that I wanted the BHR.  He told me that, all things considered (age, activity level, amount of healthy bone, etc.), I was in a gray area 50% leaning toward resurfacing and 50% toward THR, and that he would be willing to do either.  He said that a THR would probably last me 25 to 30 years (I'm 55).  I do a lot of walking, hiking, rowing (indoor), swimming and golfing, but no running.

I went home and gave the choice some more consideration for a few more days.  If I went with the THR I could probably get both sides done at the same time.  Dr. Ball said that he's done bilateral resurfings in one precedure but that he prefers not to.  I'm a fairly large person, which probably makes the surgery that much more difficult.  In the end I'm still going with the BHR but I also greatly appreciated Dr. Ball's willingness to discuss all of the ramifications and leave the final decision up to me (and my wonderful wife who will be caring for me).

[fenceman]

3 years ago when I was doing my research I went to a Ortho center that told me I should have a THR and that he would not recommend a BHR.  Turns out that they did not offer BHRs at the time.  I did my own research on this site and had Dr. Brooks do my BHR over 2 years ago.  I have been very happy with the results and am a very active 46. 

Since that time that Ortho center is now offering Hip Resurfacing. 

[Tin Soldier]

My first ortho doc at our local clinic didn't mention re-surfacing (RS), potential arthroscopic work, didn't even really mention the detailed condition I had (FAI).  "you got bilateral OA, you need new hips, take up golf so you can use the club as a cane, and then come see me in 5 yrs for some new hips".  At 41 yrs old, I was pretty shocked.  A coworker received a THR from the same clinic recently and they just don't do anything but THR.  I think that is rather common.  You have go a little farther afield to find what you're looking for, but based on all the posts I've read here and talking to several really good surgeons on the subject, I think RS is here to stay and its a great way to go for an active person. 

I totally agree with the loading argument.  It sounds like it's the biggest reason why one would choose RS vs. THR.  Also, there could very well be individual conditons that a doc would use to make the determination, bone density, maybe.  I think a big steel shank in the top of the femur is going to put way more lateral stress on the bone, than a fairly thin cap on the ball of the femur.  Steel is so hard and bone is a little brittle. If I were going to walk and cycle only (very straight motions), I might be ok with the THR.  Otherwise, I'd look at RS and keep more of the architecture and material that already have.   

[gary2010]

Hello,
I also had F.A.I. and the hip wore out very fast, athlete to cripple in about 6 months, I then wasted another 18 months exploring the various options. I had been widely advised to reduce my activity level, wait 10 years and have a THR.

19 weeks into my resurfacing I am doing extremely well. I would advise anyone against having their femur sawn off unless it is absolutely mandatory! You can read a detailed account of my recovery here:
http://surfacehippy.info/hiptalk/index.php?topic=2020.0

Find a surgeon you trust and crack on with it!
Good luck G.