Hip Resurfacing with Oxinium Coating

[kelly1008]

Hi Pat,

I am a 29 year old female. About 7 years ago, I had my left hip restructured (not a replacement or partial, different procedure to keep more of my own bone) after a big fall which partially smashed the ball of my hip joint. In the last two years, my hip has become arthritic and is becoming more and more painful. I have gone to see my surgeon who, after taking a look at the x-rays and asking me about how much my hip is affecting my lifestyle, agreed that it's time to do something. I am very active (well not so much right now), but I love to hike, ski, do yoga, bike, etc. The hip resurfacing seems to be a better option for me due to my age, but my surgeon said that it's not recommended at this point for women of childbearing age to have the hip resurfacing done as there is little research on how the metal on metal ions will affect a growing baby (I just got married this spring). My surgeon did say that they are doing Birmingham Hip resurfacing with an 'oxinium coating' in other countries (not yet approved here by the FDA) and this keeps more of the metal out of the bloodstream so is a potential option. I have looked on the internet, but haven't found anything. Have you heard of this coating? Are you familliar with the recommendations for women who want to have kids to abstain from this procedure? And if so, do you have any additional recomendations?

[Pat Walter]

Hi Kelly

My best advice to you is DO NOT listen to the advice of an inexperienced hip resurfacing surgeon.  The new surgeons just starting to do the BHRs will often take the easy road and give you a THR instead of a BHR.  If you belong to the Yahoo Surface Hippy Discussion group of over 6000 people, you will hear this story over and over. 

Only the really experienced doctors will normally tell you up front if they can do a hip resurfacing and very few EVER change their minds during surgery.  That is the primary reason to use an experienced surgeon who does not mind doing difficult cases and won't cop out and give you a THR when you want a BHR.

There also have been a number of young women receiving BHRs and having children. There have not been any tests that I have read that the Metal Ion issue will hurt a developing baby.  There have been many, many discussions about this on the Yahoo Discussion Group.  I would be somewhat afraid to try a new type of BHR with a coating until there is a real track record for the hip device.

If I were you I would talk to some of the really experienced surgeons or the overseas surgeons like Dr. De Smet or Dr. Bose and ask them the questions you ask of me.  Dr. De Smet has done over 2400 hip resurfacings and Dr. Bose over 800.  They are 2 of the best hip resurfacing surgeons in the world. They do free email consultations if you send them an email and attach your x-rays digitally.  Put them into a .jpg format and let the doctors look at them.  Dr. Bose specializes in AVN cases.

Many insurance companies will cover Dr. De Smet's surgeries, but I dont think any have covered Dr. Bose.  But, if I were a young person and wanted an experienced surgeon, I would get out my credit card and get what I want.  Not listen to the inexperienced surgeons in the US.  There are some very experienced surgeons here like Dr. Gross, Mont,Su, etc.  You can see their information on my Doctors List Page.  There is also a link to how many hip resurfacings a surgeons has done on that page.

I had no insurance and could not afford surgery in the US.  I choose Dr. De Smet since I was 61 and had a loss of bone density.  I want the best in the world to do my BHR. It cost my hubby and I a total of $16,000 for the surgery, hospital and complete trip.  Best investment I ever made in my life - in my own health.  I put it on a credit card.  You can do Dr. Bose for about $10,000 complete. 

Please talk with some experienced surgeons about your worry about the metal ion questions and if you are a good candidate for hip resurfacing.  Don't use inexperienced surgeons for difficult cases.

I hope that helps some. Please let me know if I can help any further.

Pat

[Vicky]

This will be a very long response. 

There is a gal named Katie that got one of the first, actually it might have been the first protocol of the BHR device in 1991, she has gone on to have two healthy chidlren that are now ages 13 and 8.  No problems at all.  Here are two posts from her taken from the surface hippy message board:

Posted on Wed Mar 24, 2004
New to this Group
I discovered this group just a couple of days ago and am totally
amased at how many people are having/had or need resurfacing ops and
how much support is offered by fellow patients. I thought I'd share
my experience as I am an old surface-hippy,not in age but in the
number of years post op. I had mine done by Mr McMinn at the ROH in
Birmingham when the procedure was a twinkle in most peoples eyes. I
had CDH which was only diagnosed at 4yrs so I had many ops to try
to 'build' a hip socket but it finally gave up the ghost and I was
faced with either a non tried and tested new op or a THR. I didn't
think there was much choice!! I had my left hip resurfaced in
September 1991 when I was 21 - Mr McMinn was still pioneering it and
I was the youngest person to have it at that time. I had to have
bone grafting at the same time so my post op recovery took longer
than normal. I was in traction for 4 weeks & crutches for a few
months but it meant I could walk down the isle in 1992 with no hint
of a limp which made my Mum cry! 2 years later I had my first baby
followed by another one 5 years after that. My hip is still going
very strong after over 12 years.

I would encourage anyone who is worried about the longevity of this
procedure not to worry and go for it!

I am pleased to report that I had another successful check up at the
ROH with Mr Treacy on Wednesday last week (although I didn't get to
see the man himself but one of his team). It was the first check up
in 2 years and my xray showed that my hip was just as good as it was
the last time. bizarrely for about 2 weeks before I have a check up
I start limping without reaslising it, my husband is convinced it is
psychological as I stop as soon as I have had the check up!! It is
now 13.5 years and I still feel very blessed, my next check up is in
March 07 and I am hoping for the same result when I go then!

Katie
Lhip McMinn 1991

"Posted on Wed Mar 7, 2007

15.5 years on
Hi to everyone. I haven't posted on this site for a long time but I
had a check up today at the Royal Orthopaedic in Birmingham after 15.5
years of having had my resurfacing and thought I would post an
update. My check up went very well and it looks like my hip is still
going very strong. The xray showed no change since my last check up 2
years ago which I was really pleased to hear. For anyone who hasn't
read my posts before, My kids were born 2 yrs & 7 years post op and
are now 13 & 8, they are very fit & well with absolutely no signs of
any ill affects from metal ions that may or may not have passed across
to them during pregnancy. I am not a gym bunny and don't do any
extreme sports, instead I keep fit by walking (especially walking
around shops looking for shoes - I must do a ten mile hike doing that
on a saturday afternoon!!)


Katie
Lhip McMinn 1991"

As far as metal ions go, it is so far speculation that anything bad comes of it.  Here are a couple of reports on metal ions

In all three studies below, not one case ever had any negative affect due to metal ions, one showed some reduced t-cell counts with no evidence of anything negative from that the other showed that it "MAY" cause chromosomal abberations, but again with no negative consequences.  So all of these "scare" tactics still show that every single study that has been done, there has not been one single case that showed anything negative due to metal ions.  Did you realize that a lot of people take chromium supplements?  That is supposed to reduce the risk of diabetes and other things, it is actually good for you.  I just would not take any supplements containing chromium once you got your hip resurfaced.

"Metal on Metal particulates,  what’s the word on that?
The "metal ions" issue is just a scare tactic.  Here is what Dr. L.D. Dorr said at the 2004 meeting of the American Academy of Orthopedic surgeons, when speaking about long-term studies of patients with metal-on-metal total hip replacements:

There have been absolutely no complications, not a single report of cancer, in 40 years of MOM THRs.  No hypersensitivity, no reports of increased pain due to "metal ions."  He noted design improvements,use of cobalt-chrome metal, he discussed clearance rates (the kidneys do filter out the chromium).

So there's no reason to suspect that MOM resurf devices shed a harmful amount of metal ions into the blood. You can also check out
http://www.mcminncentre.co.uk/  AND
http://www.hip-clinic.com/en/html/home_en.html  for more info.

Remember also that the new “large ball” THR are Metal on Metal (MOM).  So the scare tactic from a THR doc about “You don’t want to do a Resurfacing because of metal particulates” doesn’t ring true.


Metal-on-metal bearings in old implants may cause chromosomal aberrations
Study results present more questions than answers about long-term exposure to ion debris.
By Dave Levitan
ORTHOPAEDICS TODAY INTERNATIONAL 2006; 9:9

November 2006
Chronic exposure to metal ions from early metal-on-metal hip bearings may result in chromosomal aberrations, according to recent findings, but the consequences of these aberrations remain unknown.
“Are these findings of clinical significance? We have absolutely no idea,” said Edward Dunstan, FRCS, of Stanmore, England. “Our patients are otherwise well.”
Dunstan presented results of a long-term study of the effects of metal ion debris in patients with metal-on-metal hip bearings at the British Orthopaedic Association Annual Congress in Glasgow.
Metal-on-metal bearings create more particulate debris than polyethylene, and the particulate is significantly smaller. Dunstan said that electron microscopy has shown metal debris inside the nuclei of certain cells; polyethylene debris “ends up in the cytoplasm.”
Long follow-up
Dunstan and colleagues studied 25 patients who received metal-on-metal hip bearings between 1965 and 1979.
“The average age at time of surgery was incredibly young — only 33 years of age — and the average follow-up is now 35 years” for the survivors, Dunstan said. He noted that while the acetabular cups evolved from uncemented to cemented design during the period of implantation, the bearing articular surfaces and the neck, shaft and stem did not change in terms of materials.

This image of abnormal chromosomes shows translocation between chromosomes 2 and 15 and aneupoidy loss of chromosomes 9, 16 and 17. This fluorescent in situ hybridization chromosome painting technique shows aberrations in peripheral leucocytes in a male patient with a metal-on-metal implant of 38 years duration.
Image: Dunstan E
Dunstan told Orthopaedics Today, “The bearing articular surface was always a cobalt, chromium, molybdenum alloy. The neck shaft and stem of the prosthesis was always a titanium/titanium alloy.” The Stanmore Metal-on-Metal Proximal Femoral replacement implant was used throughout the study.
The study included three groups: a control group matched for age and sex, patients who retained their original metal-on-metal bearings and patients who originally had metal-on-metal bearings, but received a revision to metal-on-polyethylene. Researchers used the 24-color fluorescent in situ hybridization (FISH) chromosome painting technique on peripheral leucocytes to map changes and aberrations in chromosomes. They examined results from 20 different cells per individual.
The FISH technique allowed researchers to view gain or loss of chromosomes and the more significant structural aberrations, Dunstan said.
“There was a significant difference between the number of structural aberrations between the control group and metal-on-metal group. There was also a significant difference in the number of structural aberrations between the metal-on-metal group and the revised metal-on-metal group. There was no difference between the control group and the revised group.”
Reversible changes
Interestingly, Dunstan said that the chromosomal changes appear to be reversible. The revisions from metal-on-metal to metal-on-poly occurred at an average of 26 years postoperatively, or approximately 10 years from the end of the study. From the time of revision to the present, those patients’ chromosomal aberrations declined.
“It may well be that the normal genetic repair mechanisms are overwhelmed or are themselves damaged by the metal ion load,” Dunstan said.
Because this study focused only on peripheral leucocytes, researchers could not determine the overall effects of metal ion wear.
“Are these changes replicated in other tissues in the body? There is evidence from retrieval analysis that they do occur in bone marrow,” Dunstan said. “What about reproductive cells? We just don’t know. But what is absolutely sure is that we must monitor the long-term biological effects of metal wear debris.”
For more information:
• Dunstan E, Ladon D, Whittingham-Jones P, et al. Chromosomal aberrations in the peripheral blood of patients with metal-on-metal hip bearings. Presented at the British Orthopaedic Association Annual Congress. Sept. 27-29, 2006. Glasgow. “

In summary of the above,  basically there is still no proof that there is any damage that is caused by metal, just that metal implants "MAY" cause chromosomal aberrations and that even when it does, the consequences are still unknown even after a patient has had the implant for 38 years.

“The Association between metal implants and reduced T-cell counts


A. J. Hart, MA, FRCS(Orth), Specialist Registrar1; T. Hester, BSc, Medical Student1; K. Sinclair, PhD, Senior Research Analyst2; J. J. Powell, PhD, FRSC, Professor2; A. E. Goodship, BVSc, PhD, MRCVS, Professor1; L. Pele, PhD, Career Development Fellowship2; N. L. Fersht3; and J. Skinner, FRCS(Orth), Consultant Orthopaedic Surgeon1
1 Institute of Orthopaedics and Musculoskeletal Science, Royal National Orthopaedic Hospital, University College, London Campus, Middlesex, HA7 4LP, UK.
2 MRC Human Nutrition Research, Elsie Widdowson Laboratory, Fulbourn Road, Cambridge CB1 9NL, UK.
3 Cell Cycle Laboratory, Cancer Research UK London Institute, 44 Lincoln’s Inn Fields, London WC2A 3PX, UK.
Correspondence should be sent to Mr A. J. Hart; e-mail: alisterjhart@yahoo.com .


We have studied the relationship between metal ion levels and lymphocyte counts in patients with metal-on-metal hip resurfacings. Peripheral blood samples were analysed for lymphocyte subtypes and whole blood cobalt and chromium ion levels in 68 patients (34 with metal-on-metal hip resurfacings and 34 with standard metal-on-polyethylene total hip replacements). All hip components were radiologically well-fixed and the patients were asymptomatic. Cobalt and chromium levels were significantly elevated in the patients with metal-on-metal hip resurfacings, compared with the patients with standard metal-on-polyethylene designs (p < 0.0001). There was a statistically significant decrease in the level of CD8+ cells (T-cytotoxic/suppressor) (p = 0.005) in the metal-on-metal hip resurfacing group. A threshold level of blood cobalt and chromium ions was associated with reduced CD8+ T-cell counts. We have no evidence that our patients suffered as a result of this reduced level of CD8+ T-cells. “

In summary of this one above, again, no evidence that anything negative came of the reduced T cell counts

Vicky