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Author Topic: Trochanteric Flip and long term care  (Read 1261 times)

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jalanjalankt

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Trochanteric Flip and long term care
« on: October 16, 2011, 08:28:51 AM »
I had the trochanteric flip procedure and now am at 10 months post-op and feeling good.   I wonder who out there has a few years in and what your long term results have been.  I am avoiding running - still can't do it comfortably anyway, and putting a lot of miles on my bicycle. 

I have a blog I update now and then which I started after the surgery since I could not find many blogs about the trochanteric flip resurfacing procedure.   It would be really interesting to compare my surgery to someone who had the standard surgery via the posterior approach.  Basically to find out if the theory about saving the blood supply to the femoral head has any long-term warrant. 

Note by Patricia Walter:  All the surgeons using the posterior approach save the femur neck tissue.  It is important to keep the blood supply normal.  This is not an issue with the posterior approach.  It it were, then there would be a hundred thousand plus folks with BHRs and resurfacings that needed to be revised.  Please understand resurfacing has been done since 1991 and a few before then.  The retention rate for all BHRs nationwide is 96%.  It use to be 99% before the US surgeons started doing them.  The inexperienced surgeons learning curves brought the retention rate down.  The posterior approach is safe, preserves the blood supply and is used by probably 99% of the surgeons - and used sucessfully. I place this note in your post because it is important for new people to understand what you are saying is your opinon and not based on medical fact.  



Jalan jalan
« Last Edit: June 30, 2013, 08:50:54 PM by Pat Walter »

Lopsided

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Re: Trochanteric Flip and long term care
« Reply #1 on: October 16, 2011, 11:20:45 AM »
Hello there Walking Walking. This T rex thing is certainly being talked about a lot lately on this forum.

It seems to me that, only the surgeons that do the T rex believe there is an issue with blood supply from a conventional approach. Of all the complications that can arise from resurfacing, blood supply seems to be low, if anywhere, on the list.

My surgeon, as many, uses the posterior approach and importantly preserves the hip capsule. This is essential for blood supply.

Where I do think you have got it spot on Sid, is your preference for tropical climate.

D.




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Pat Walter

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Re: Trochanteric Flip and long term care
« Reply #2 on: October 16, 2011, 02:02:06 PM »
I just watched a live surgery as Dr. Kusuma of Columbus did a BHR hip resurfacing with the posterior approach.  I have to tell people that surgeons are very careful to keep as much tissue around the femur neck and at the hip capsule as possible - that is what allow the blood supply to be as normal as possible.  Pease understand that the BLOOD SUPPLY TO THE FEMUR NECK AND TISSUE is NOT a problem with the posterior approach. The surgeons have known for a long time how to preserve the blood supply so there is no damage.  I want perspective patients to understand the posterior approach is used in almost all hip resurfacing surgeries and when done well presents no problem.  The skill of the surgeon is most important.  It is also a fact that the anterior approach can case severe nerve damage when not done well.  So the important fact is to choose the most experienced surgeon you can for either surgical approaches.

I also must, once again, remind people that your recovery for the posterior approach is not slower than the anterior approach.  It all depends on the surgeons skill.  I know a lot of people including myself that used no meds than asprin or advil after leaving the hospital in 2 1/2 days, used one crutch for several weeks and then none.  I was doing deep knee bends at 6 weeks.  I was sight seeing in Belgium at 5 days post op.  I was 100% weight bearing at the hospital.  It is diffiuclt to do, but there is no reason that a person can't be full weight bearing as soon as then are able.

There are a lot of points being made by the anterior approach folks telling others that it is the way to go because there are too many problems with the posterior approach.  If you study the national registries and other medical studies, you will find almost all resurfacing is done with the posterior approach and the patients recover fine.  Some very quickly while others take longer.  There are no long restrictions like not full weight bearing for 8 weeks or not a lot of walking, etc.  You are able to do whatever your body will allow as quickly as you wish.  The problem is too many people feel so good that they overdo things and do them too quickly.  That certainly should tell perspective patients that if you feel so good you think you can do anything early on - then there is no problem with the posterior approach.

There is not a lot of information about the trochanteric flip because it is an old version of surgery and not used by hardly any surgeons.  I asked Dr. Kusuma about it recently and he said "why in the world would any surgeon use such an old fashioned method.  It has no advantages over the normal posterior approach and causes a very slow recovery."

I could get other surgeons opinons, but it is obvious if it were a better approach to hip resurfacing, then many surgeons would be using it.  It is not used by the top experienced hip resurfacing surgeons.

Pat
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3/15/06 LBHR De Smet

jalanjalankt

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Re: Trochanteric Flip and long term care
« Reply #3 on: October 18, 2011, 11:39:58 AM »
Yes Pat, that is good information. Am I correct in that typical total hip replacements use posterior approach or is it anterior?  The 3 techniques in my non-professional understanding  have a bias that drives them.   One article I read about the blood supply had only done testing on the supply while the leg was still surgically open.   Is it possible to isolate the vessels 12 months post-op?   Now that would make the whole blood supply debate interesting! 

Pat Walter

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Re: Trochanteric Flip and long term care
« Reply #4 on: October 18, 2011, 01:59:44 PM »
Instead of my explaining the approaches, I am going to post Dr. Brooks information from his interview page  http://www.surfacehippy.info/doctorinterviews/brooksinterview.php



Dr. Brooks of the Cleveland Clinic with over 1100 resurfacings explains different surgical approaches.

Explain the surgical approaches to hip resurfacing and what approach you prefer

Most hip replacement and resurfacing surgery in the USA, about 80%, is performed through a posterior approach. About 20% of US hip surgeons prefer some variation of an anterior approach (antero-lateral, direct lateral, trans-gluteal, or true anterior). Anterior approaches are also more common in Europe and Canada.

 In the posterior approach, the incision, dissection, and dislocation of the hip joint are all performed posteriorly (toward the buttock). The large gluteus maximus is split, and the gluteus medius and minimus muscles (hip abductors) are retracted, but not cut. A number of smaller muscles, the "short external rotators" including piriformis, obturator internus, gemelli, quadratus, and obturator externus, are cut, and the tendon of gluteus maximus may also be partially divided. With these out of the way, the posterior hip capsule is incised, and the hip is dislocated posteriorly by turning the foot toward the ceiling. The acetabulum and femoral head are then resurfaced, the muscles and capsule are repaired, and the incision closed.

 In the direct lateral approach, (or trans-gluteal approach as it is also known), the incision is on the side of the hip, and from there the dissection proceeds towards the front of the hip joint. The hip abductors (gluteus medius and minimus) are split in the line of their fibers, peeled off the greater trochanter of the upper femur in continuity with upper fibers of the vastus lateralis, and retracted anteriorly, allowing the anterior capsule to be cut, and the hip to be dislocated anteriorly, with the foot pointing down to the floor. During closure, these muscles all tend to lie back where they belong, and since they have not been cut across their fibers, there is no tendency for their repair to pull apart. The antero-lateral approach is similar, but retracts or detaches, rather than splits, the abductors.

 The true anterior approach can be adapted to hip resurfacing, actually better than for hip replacement, since exposure to the shaft of the femur is difficult (and not needed in resurfacing). It is not popular among surgeons who operate on adults, but is fairly common in pediatric orthopedics.

 Different approaches have different issues. The posterior approach is very well known in the USA, and BHR developers Mr. McMinn and Mr. Treacy use it routinely as well. Theoretically it should have a higher dislocation rate, due to the fact that dislocation almost always occurs posteriorly, and this approach disrupts all the potential restraints to posterior dislocation. But dislocation after hip resurfacing is much less of a problem than it is with hip replacement, due to the very large head size. The blood supply to the femoral head stands a greater chance of damage through the posterior approach, since that is where the vessels mostly are. The important hip abductors (gluteus medius and minimus) are left completely intact.

 The direct lateral (trans-gluteal) approach has the advantage of a lower dislocation rate, and less likelihood of damage to the blood supply of the femoral head. In addition, no muscles are actually cut across; they are just split, or teased apart in the line of their fibers, which should lead to more reliable healing. The exposure of the socket is a "straight shot", since the acetabulum is an anteriorly facing structure. The disadvantages are that there is nonetheless surgical trauma to the abductors which, if substantial, could cause a limp. There are also reports of heterotopic ossification, although this may occur with any approach.

 The true anterior approach can be associated with injury to a sensory nerve responsible for the side of the thigh (lateral femoral cutaneous nerve), and the location of the incision in the groin is not the cleanest part of the body. It is also by far the least commonly used of these incisions for adult hip surgery, so at least for the time being, we do not have a lot of data.

 The main thing to keep in mind is that any of these surgical approaches can work just fine. All have been modified in many ways as surgeons find better ways to do things. The most important thing for a patient to decide is who will do their surgery, not how it will be done. The surgeon, drawing on his or her own training, experience and beliefs, will decide what works best in their hands.
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hernanu

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Re: Trochanteric Flip and long term care
« Reply #5 on: October 18, 2011, 05:13:34 PM »
Hi jalan, I had a direct lateral approach on both of mine, and have had no issues (I'm at 11 months and 14 months). Pat has provided you with a lot of good information here, and the upshot of it is based on the actual results from the aggregate efforts of some talented surgeons.

If the trochanteric approach were addressing a serious problem with blood supply, then you would see many more failures in non-trochanteric approaches. Just simple logic would tell you that. One result of a serious problem would be an elevated number of neck fractures, but you have not seen that. The long and short of it in my opinion, is that if it is not frequently used, and yet the other approaches have great results, it is not necessary for a good outcome.
Hernan, LHR 8/24/2010, RHR 11/29/2010 - Cormet, Dr. Snyder

 

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