2011 Australian Registry p.87 Aussie Hip Resurfacing continues to decline

[Tim Cunningham]

Hi...I'm new to this posting site and scheduled to have BHR March 7th at The Cleveland Clinic w/Dr. Brooks

Looking at The Australian Registry for 2011 concerned me in that the Australians continue to opt away from Hip Resurfacing since a peak in absolute numbers in 2005, per the excerpt below and if you have insight or comments please advise me, Tim Cunningham 321 757-3733.


Primary Total Resurfacing Hip Replacement
Demographics
There have been 14,298 total resurfacing procedures
reported to the Registry, an additional 991 procedures
compared to the last report.
The use of resurfacing hip replacement in Australia
continues to decline.   The number of procedures
reported in 2010 was  22.1% less than  in  2009 and
48.6% less compared to the peak in 2005. 
Osteoarthritis is the principal diagnosis for total
resurfacing hip replacement (94.8%), followed by
developmental dysplasia (2.6%) and osteonecrosis
(1.8%).   
Most patients are male and the proportion of males
has increased from 71.2% in 2003 to  91.0% in 2010
(Figure HT33).

[Dannywayoflife]

I think that a lot of people have been put off by the one sided negative media. Until smith and nephew come out and silence the negativity with the real truth I think people will continue to be put off by this negative press. Very sad.

[Luanna]

What strikes me as significant is the decline of women receiving hip resurfacing. This procedure says that in Australia in 2010 - 91% of people having HR are males. I'd be curious as to know how that compares to European registries. Since we don't have registries in the US it makes it hard to see trends here.

This report is disturbing...

Luanna

[hernanu]

I think Danny has hit it on the head. The unwarranted bad press of good HR outcomes (as supported by the Australian registry) is having its effect, herding people from HR to THRs or (tragically to me) they may be putting off surgery altogether, putting up with that pain.

One of the things that the press emphasized was that HR was much worse for women; this seems to have affected the number of women electing HR, as seen by the increase in percentage of men vs. women having it.

Very sad to me, as this is surgery that has been a lifesaver.

[Luanna]

And/or is it impacting the number of physcians who are willing to do the procedure on women? and not just that the women are not opting for the procedure?

[hernanu]

Yup, you are right, Luanna.

[Pat Walter]

Although there are fewer hip resurfacings in Australia and in some other countries, it is still an excellent solution for hip problems.  The overall retention rate of the BHR world wide is 96%   That is an excellent record.  There has been a lot of negative info recently based on half truths. Many surgeons had problems with their resurfacings since it is a difficult surgery and those problems make resurfacing look bad.  Many have stopped doing resurfacing and now there are fewer hip resurfacing surgeons, but they are becoming highly skilled.  Surgeons like Dr. Brooks have excellent records and I would not hesitate to use him myself.  Since 2005, when I started this website, I have always suggested only using the top experienced resurfacing surgeons.  They have excellent retention rates.  I went to Belgium in 2006 because I wanted a really experienced surgeon to do my resurfacing. 

The lessons I have learned since 2005 is that the top experienced resurfacing surgeons have excellent outcomes while the less experienced have more problems and revisions.  Many of the top surgeons think hip resurfacing will continue to be an excellent option.  Most of the current video interviews I have done with the top surgeons explain their opinions about resurfacing and all the negative media info.  http://www.surfacehippy.info/shvideos/videosdoctor.php

I know people keep asking how long their hip resurfacings will last and what is the revision rate, but they seldom take time to ask the same questions about THRs.  THRs are not perfect and have many problems also.  Those show up in the National Registries, too.  There is no 100% perfect solution for a hip replacement.  It is difficult for man to design a device that will ever be as good as the original equipment.  Meanwhile, we accept the devices that seem to have excellent outcomes and that includes the BHR. 

Pat

[Nemesis]

PAt what do you mean by "a retention rate of 9.6"?

[dwbitt]

I believe that will be a misplaced decimal and the rate is 96% for all THR's.

[Dannywayoflife]

I believe that will be a misplaced decimal and the rate is 96% for all THR's.

It's 96% retention for the BHR

[curt]

        What I fail to understand most is the whole idea that the chance of a failed HR makes it an unacceptable option.  If you needed a new liver, would you decline because it isn't 100 percent guaranteed?  The fact is that the requirement for a revision is a distinct possibility when one gets a Hip Resurfaced, a small one, but a possibility nonetheless.  If that happens, you get the THR anyway. 
        There are rotten and unlucky outcomes with almost any surgery, which is why you can't treat it like a visit to the botox man.  We better our chances by picking the best surgeons we can find or afford and then hope for the very best outcomes.  If all the stars align against me and I need a THR revision, I will have counted the risks versus the reward as having been worth it and I will still be better off than the condition I was in pre-op.  The obvious advantage is that if it does hold I can be more active and it might last significantly longer than a THR...we'll see.
         The negative press, and worries about metal on metal, and the frightening possibility of needing a revision shouldn't dissuade people from an HR...I mean what are the options?  Simply opting for a THR is in fact, what the revision would have resulted in, and while saving one from a major surgery, dismisses any chance for the increase in longevity and activity that the HR might have.  The other option seems to be to do nothing at all and simply bear it.
          I would be very interested to have Pat ask the question about how long HR patients would have been willing to "do nothing", vice going with a THR.  As an example, I would not have made it another 6-12 months before I was on full disability and sitting in a chair on drugs.  For me the surgery was a God-send, even if it doesn't hold up.

As always, this is just IMHO,
Curt

[Boomer]

There is considerable debate going on around the world regarding hip resurfacing. The agenda for the upcoming Academy of Orthopedic Surgeons Is filled with topics related specifically to hip resurfacing. I don't look at this as totally negative. The results for resurfacing have not been as good for small boned women. What's wrong with sharing that data and having a discussion about why the outcomes have not been as good? What's wrong with publishing the data on metal on metal issues and having a debate about that? Also, I think it's wonderful that inexperienced surgeons, and surgeons who lack confidence in resurfacing are abandoning the procedure. Perhaps it should be left to specialists.

Hip resurfacing has been a Godsend for many people posting on this website. The prostheses and the procedures will get even better in the future as a result of study and debate about the past successes and failures. We should look forward to hearing about the results of the upcoming AAOS. I think a lot of the misinformation being published will be replaced by real data and hopefully some consensus from the Orthopedic Surgery community on candidates, procedure, pain management and recovery.

Those who are interested can access the meeting agenda on the AAOS website. The agenda also indicates which Orthopedic Surgeons are participating in the panels and debates. There are some very good resurfacing surgeons leading the way.

Some countries like Sweden and Australia are moving away from resurfacing, which frightens many on this site. Consider that the successes being had by the resurfacing surgeons in the US may turn the tide internationally back toward resurfacing once some of the issues like perceived problems with small bones women and metal on metal issues are opening discussed and resolved. Don't lose hope. Medical procedures are driven by demographics and patient demand. There is a huge wave of baby boomers asking for innovative treatments to enable them to continue to lead active lives.

Boomer

[Pat Walter]

I am sorry about the typo.  I meant the BHR has a retention rate of 96%   That means 96 people out of 100 will have no problems and hopefully will keep their BHRs a very long time.  Right now the registries don't go back to 1997 when the first BHRs were placed.  That statistic also means 4 out of 100 people will have revisions or problems.  The way to make sure you are not a statics and one of those 4 people is to use the very experienced hip resurfacing surgeons.  They have very few problems.

I think we should all be interested in real medical studies, surgeons' series of resurfacings and national registries.  That is where we get our legitimate statistics. 

I attend hip resurfacing courses and the one thing that is discussed over and over is that patients should use the really experienced surgeons. The teaching surgeons suggest that if there is a group of orthopedics in one office, that only one does resurfacing so he does them often and gets experienced.  That is better than each doing a few now and then.  So experience is still the most important factor in choosing a surgeon according to the surgeons teaching and the statistics.

We also have to understand that any major surgery can have problems.  Surgeons are cutting our bodies open and fixing or replacing parts. We are all designed a bit differently as humans and the surgeons have to adjust for this.  I am actually in awe that they can even do what they do!  You can't get a 100% outcome warranty with any surgery - it is not possible.  So you do your homework and choose the surgeons that have the least problems.  You also can't stay in pain because you might have a small chance of having problems.  I had to have an aortic valve replacement by open heart surgery or I would die within a year or two.  The statistics are that 1% have problems or die during surgery at some facilities.  So I chose Cleveland Clinic which is number 1 in the country and chose a surgeon that had placed 3000 valves.  He does them all the time.  I knew I could die, but the chance was very slim.  Actually at the Cleveland Clinic, their outcomes with minimally invasive aortic valve replacement has not had any deaths.  Minimally invasive still means they cut your chest open, but don't crack the whole chest and it still means you lay there for 6 hours on a heart and lung machine.  So it is very major surgery, but just a bit of a different technique.  The moral of my story is - do your homework and keep your odds of having problems to a minimum.

The top surgeons think hip resurfacing will always be a solution for the proper, active candidates, but there seems to be fewer done now.  I have heard them say that they think it will come back - but who knows.  All of the negative media is not helping.  The ASR did not help.  It is a shame to have so much bad press about a surgery that can be very successful.

Pat

[hernanu]

Boomer, I agree that we need real hard data, but that is in fact what Pat has provided here. If you look at the Australian national registry, you see both the retention rate and revision rates for both HR and THR in Australia.

I've read the thing front to back and it supports my belief in HR. The data is there, for anyone (NY TIMES?) who wants to read it. It makes the decision by some to move from HR even more poignant, since to me the risk is worth it.

We've talked a lot about metal ion issues, but if you look at the data, you'll find that in Australia, the metal ion revisions are much lower than those from other reasons:

(Quoting from the Australian report)

"The main reasons for revision of primary resurfacing hip replacements are loosening/lysis (34.8%), fracture (32.3%), infection (8.0%), metal sensitivity (8.0%) and pain (5.6%) (Table HT63)."

and about the overall revision rate in Australia over the course of ten years:

"The cumulative percent revision at ten years for primary total resurfacing hip replacement undertaken for osteoarthritis is 7.5% (Table HT62 and Figure HT35"

(Both from page 105 of the 2011 report). What this says is that over the course of ten years, whether from improper placement of the devices, infection, fracture, all possible sort of medical reasons, 92.5% of the devices were still in place and functioning well. The revision rate over each year was about 1.2-1.5% per year.

Of the remaining 7.5%, the types of revisions were (again, quoting):

"The main types of revision of resurfacing hip replacement are isolated femoral (48.2%), total hip replacement (41.7%) and acetabular only (6.8%) (Table HT64).".

Which means that of all revisions, (48.6 + 6.8 %) 55.4% were revised so that the HR still was in place. This means that even when there was an issue serious enough to require a revision, the revision was to allow the patient to keep the HR. Doing some math, that increases the viable HR population in Australia to 92.5% (population without a problem) + (.554 * 7.5) 4.155% (revised to HR) = 96.66% people in Australia who were healthy and functional with an HR. The remainder, I assume were healthy and functional with a THR.

I don't see the need for a panic if you follow logic. The data is there, the country is large enough and the statistical data gathering is responsible enough to be credible. I still see a surgical procedure with a very high success rate, with a positive alternative (THR).

BTW Curt - the mortality rate for botox is 3% ... for procedures done by qualified people.

http://www.surgery.com/procedure/botox/morbidity-mortality

Apparently that is acceptable for the people having that done. 

[Luanna]

Hern,
Thanks for the analysis. Well done. But...don't try to take my botox away!!!

Luanna

[hernanu]

Thanks Luanna, but I think you're beautiful just the way you are 

[Two4One]

Also, I think it's wonderful that inexperienced surgeons, and surgeons who lack confidence in resurfacing are abandoning the procedure. Perhaps it should be left to specialists. - Boomer

Quite right, Boomer.  The way it stands in the U.S now is that ANY Orthopedic Surgeon who feels like "getting into the the business" of doing arthroscopic surgery or hip resurfacing CAN - without in depth training, without practicing on cadavers, and without any negative financial repercussions.  Thus, inexperienced surgeons 'practice on them' - the patients unknowingly getting substandard medical care, the patients unwittingly being nothing more than human guinea pigs, and the patients desperately having faith 'their' surgeon knows what they are doing and will do them no harm.  These inexperienced surgeons are not only unconscionable in their practice of medicine, but in my opinion criminally and morally bankrupt.

It's really no surprise our laws allow surgeons to be gods, doing as they wish without oversight or requirements for special training to do highly specialized, cutting edge procedures.  We are, after all, one of the countries who think it's citizens should basically die if you can't afford the spiraling cost of health insurance or life preserving surgery.  Our health care, and especially our allowing surgeons to 'practice' any way they wish with out adequate protections in place for unsuspecting patients, is a crying shame.

[Dan L]

One of the data points involving revisions, which may be important to keep in mind, is the human element and behavioral differences in the management of the implant by those who recieve it, particularly in light of the different protocols every surgeon seems to use to restrict activity following the surgery.

Along with poor placement, surgeons who are inexperienced, and failures of certain devices (for any number of reasons) some unknown (and potentially unknowable) percentage of failures are certainly attributable to the actions of the persons who get the implant, via not following restrictions, their surgeon providing different restrictions that may increase the risks, weight gains, unforseeable accidents, high impact sports, etc, etc.  The very active population who get this done, are, well, very active and will remain that way when/if they can, which is completely understandable and expected, but that personality type does raise the risk of failure, just by virtue of who they are, and how they choose to live their lives, and doing what is very important to them.  Very active persuits like many here undertake, love and live for are going to cause failures for some people, at some point.

Conversely those who are much less active are not really condidates for this procedure, therefore impacting the statistics in the other direction for retention by individuals who do not put the implant to the test in very active persuits, and therefore would seemingly have a lower risk of activity-induced failures.  Many who get THR are in that population group, it would seem.

That is not a statement "blaming the victim" on any level, just an acknowledgement of the high level drive to be incredibly active many who get this done have, that adds to the overall stats on performance and revisions, based simply on the target population characteristics.

[Two4One]

Cheers Tim,

This is a very interesting conversation about the Australian registry.  It's sort of a Rorschach in the way you view the article through your own lens and experiences.
 

The very active population who get this done, are, well, very active and will remain that way when/if they can, which is completely understandable and expected, but that personality type does raise the risk of failure, just by virtue of who they are, and how they choose to live their lives, and doing what is very important to them.  Very active persuits like many here undertake, love and live for are going to cause failures for some people, at some point......

....not a statement "blaming the victim" on any level, just an acknowledgement of the high level drive to be incredibly active many who get this done have, that adds to the overall stats on performance and revisions, based simply on the target population characteristics.- Dan L

You're preaching to the choir, Dan L, IMHO.  I am afraid for all the gifted athletes who run on 'heavy, heavy fuel' pushing past what our bionics and bodies are ready for - protocol be damned. They seem to be busting out of their fitness timelines way before the One Year Mark; I'm guessing because they are giddy with the freedom from their miserable, debilitating pain bondage.  As a newbie, it looks to me that the 'highly driven types' have a 'It doesn't hurt, so surely this can't hurt to do X!' mentality that goes hand in glove with breaking protocol, magically thinking they are the exception to the absolute healing time periods, and run a real risk of dislocating their hardware or, God Forbid, breaking a femur.

So yeah, Dan L, if you're sedentary type person with end stage OA, you're probably not even thinking about, let alone doing, sports or working out your body for fun, and so a THR is just fine in your book.

Different strokes and all that. 

'One 

[Barbara]

I used to post on here often but stopped because of things like this. I love this site but find it site is very one sided and  people only wants to discuss positive outcomes. I understand the rationale for keeping things positive and extolling the virtues of hip resurfacing as opposed to Total hip replacement, however please don't dismiss the fact that there are a growing number of failures out there.
This is not one sided negative media and Smith and Nephew will never come out and silence people for speaking out. There are a lot of failures out there. Thank god that some countries are keeping registrys, it's time the US were too. I know of quite a few S&N failures, we are growing in number.
I am now recovering after my 5th surgery in 3 years. I had a very experienced surgeon and perfectly placed/angled cups. Dr Pritchett is now concerned over the failures in women and is advising them of the risks of metal on metal in women.