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Author Topic: Dr. Su responds to the recent Lancet article  (Read 6886 times)

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Pat Walter

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Dr. Su responds to the recent Lancet article
« on: October 27, 2012, 08:29:35 PM »
Here is Dr. Su's response to the Lancet Article about Hip Resurfacing.

http://www.edwinsu.com/su-responds-to-the-recent-lancet-article.html


I would like to take this opportunity to comment on the Lancet article, "Failure rates of metal-on-metal hip resurfacings: analysis of data from the National Joint Registry for England and Wales", by Professor AW Blom, published on October 2, 2012.

First of all, this is an observational scientific study with valid research design and questions; however, the conclusions point out the limitations of registry studies (more on this to follow). Overall the conclusions of the study do NOT find any new information that has not already been known since 2010: that certain hip resurfacing implants perform better than others; that females do worse than males with hip resurfacing; and that larger size implants have a lower revision rate. These key pieces of information have been well-known and discussed by experienced hip resurfacing surgeons with their patients for at least 2 years already. Furthermore, there are scientific congresses and courses that have help spread this information to surgeons, including the course that I chaired in May 2010.

What is new in this paper is the comparison to cemented, hybrid, and uncemented total hip replacements (THR) of various head sizes; the conclusion is that hip resurfacing has a higher revision rate than any of these methods of total hip replacement for most patients, and is not suitable for most patients. The data cited is that 5 year revision rates for 55 year old men was 2.6% with a 54mm hip resurfacing femoral head, and 1.9% with a 28mm cemented metal-on-polyethylene THR.

As this study was performed in the UK, I would like to point out that fully cemented THR is not often performed in the United States. In fact, it represents less than 5% of all THR done in this country, and is on the decline. So, these findings may not be applicable outside of the UK.

In looking at the data presented, there are actually some comparable rates of survival between hip resurfacing and the type of THR most commonly performed in the US. Namely, hip resurfacings with femoral head diameters of 50mm had a 5 year revision rate of 4.2%; 52mm was 3.77%, and 54mm was 3.37%. For hybrid THR with a 28mm head, the 5 year revision rate was 4.1%, and an uncemented THR was 4.18%. When divided by gender, the results for males are even better. Men aged 55 years with a resurfacing implant of 50mm had a 7 year revision rate of 3.27%; a 54mm head diameter was 2.47%.

Limitations of registry studies

The problem with a registry is that it collects a little bit of information about a lot of people. Therefore, the outcome measure that Professor Blom uses, revision rate, is a crude indicator of how the implant is performing. Revision rate will only include those patients who undergo a second, or revision operation. It does not include those patients who have had dislocations of their hip, or thigh pain, as many of these patients will not have revision surgery for these problems. It is an established fact that the dislocation rate after hip resurfacing is about 10x lower than for THR; thus the registry is not able to capture all the THR patients who have had a complication such as dislocation or thigh pain from the stem of the implant. Therefore the reported superiority of THR has only to do with revision, and does not include complications.

Besides a complication such as dislocation, the registry does not have clinical information about how the patients are functioning. Are the hip resurfacing patients participating in more activities? Are they more satisfied with their hips? Is their range of motion superior? Who has a more normal gait? The registry is not able to answer these questions – if a hip operation gave superior function, some patients would consider it a worthwhile operation despite the slightly higher risk of revision. There have been several studies that demonstrate that hip resurfacing patients are more active and have a higher satisfaction rate than their THR counterparts.

Finally, a registry study is not able to account for surgeon practices with regard to revision surgery. There is a particular type of knee replacement, called a hinged knee, that has a 100% survivorship in a national joint registry. However, this is because there is no revision possible for this type of implant – it simply cannot be revised because it is an implant done for “last-resort” situations. Therefore, in looking at the registry results, one could conclude that this is the best implant available, a conclusion that is clearly erroneous. What this registry is unable to adjust for is the likelihood of revision based on the type of implant. I can tell you from experience that revising a hip resurfacing is the easiest revision to perform; next is an uncemented or hybrid THR; and hardest to revise is a cemented THR (because the parts are not easily exchanged). Therefore, the registry results may be reflective of the tendency for surgeons to indicate the easiest type of revision operation.

Conclusion

I believe that there is valuable information from this study, one that highlights the importance of patient selection for hip resurfacing. However, I don’t feel that it provides the entire picture of comparing patient activity, function, and complications between the two procedures. I also look to other international studies, particularly the Australian National Joint Registry. Their 2012 report demonstrates a revision rate of 4.2% at 7 years, for men younger than 55 years who had hip resurfacing; their THR counterparts had a 7 year revision rate of 4.6%. Thus, in this patient population, hip resurfacing has a lower 7 year revision rate as compared to total hip replacement.

The study by Blom et al. fails to account for the countless lives that have been returned to one of function and activity by hip resurfacing, which is why I don’t agree with the recommendation of denying my patients this alternative to total hip replacement.
« Last Edit: December 11, 2012, 10:01:01 PM by Pat Walter »
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Baby Barista

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Re: Dr. Su responds to the recent Lancet article
« Reply #1 on: October 28, 2012, 01:26:31 AM »
Then Dr. Su dropped the mic and walked off stage.
LBHR Pritchett 01/23/12 - 52mm head, 58mm cup
RBHR Pritchett 12/10/12 - 52mm head, 58mm cup

Tim Bratten

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Re: Dr. Su responds to the recent Lancet article
« Reply #2 on: October 28, 2012, 01:32:31 AM »
Hey! that's pretty much what I was thinking!
Botched LHR by Dr. Vilicich 06-17-2010 revised by Koen De Smet 02-14-2012
RHR Koen De Smet 02-05-2014

Tin Soldier

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Re: Dr. Su responds to the recent Lancet article
« Reply #3 on: October 29, 2012, 07:58:30 PM »
Agreed.  Nailed it.  This is great that we get to hear from someone like Dr. Su on this.  Every article and study that we see that has some bias or maybe some poor or unsupported recommendations needs to have a review from somene like this. 
LBHR 2/22/11, RBHR 8/23/11 - Pritchett.

lycraman

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Re: Dr. Su responds to the recent Lancet article
« Reply #4 on: October 30, 2012, 06:21:57 PM »
Hi Pat.  Please say thanks to Dr Su for such a comprehensive response (demolition) of the Lancet article.  Unfortunately the Lancet is an opinionated political rag these days. Do you know if Dr Su (or anyone else) intends to respond to the Lancet with his enlightened comments?
Left Birmingham Hip Resurfacing
11th September 2012
Mr Ronan Treacy 54mm head 60mm cup

Pat Walter

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Re: Dr. Su responds to the recent Lancet article
« Reply #5 on: October 30, 2012, 07:44:02 PM »
I don't know if Dr. Su or any other doctor will reply to the Lancet. The article above is from Dr. Su's website.  I did not talk to him personally. 

Pat

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lycraman

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Re: Dr. Su responds to the recent Lancet article
« Reply #6 on: October 30, 2012, 10:55:47 PM »
Thanks Pat

It would be nice if someone would respond, otherwise the original goes without challenge in the literature.
Left Birmingham Hip Resurfacing
11th September 2012
Mr Ronan Treacy 54mm head 60mm cup

jono

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Re: Dr. Su responds to the recent Lancet article
« Reply #7 on: November 01, 2012, 11:02:22 AM »

This article appears to have been more about getting headlines than progressing the academic debate. As a Brit who has many family members who are doctors I am sad to say these articles often have a level of professional jealousy behind them.

More people who get a HR wish to lead an active live than a THR and this inevitably means there is a greater risk of damage to the hip. If the difference is maybe 1% over the next 10 years then I can tell you I will not be sitting in my armchair but on the ski slopes.

This website does a great job as it shows the impact that HR can have on people's lives on a day to day basis. Last week I did a 30 miles charity cycle 2 months after my HR operation and went for a drink afterwards without feeling pain. As they say in the advert "the value of this: priceless"
Gaston LBHR   14/08/12

lycraman

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Re: Dr. Su responds to the recent Lancet article
« Reply #8 on: November 02, 2012, 10:57:38 AM »

This article appears to have been more about getting headlines than progressing the academic debate. As a Brit who has many family members who are doctors I am sad to say these articles often have a level of professional jealousy behind them.

More people who get a HR wish to lead an active live than a THR and this inevitably means there is a greater risk of damage to the hip. If the difference is maybe 1% over the next 10 years then I can tell you I will not be sitting in my armchair but on the ski slopes.

This website does a great job as it shows the impact that HR can have on people's lives on a day to day basis. Last week I did a 30 miles charity cycle 2 months after my HR operation and went for a drink afterwards without feeling pain. As they say in the advert "the value of this: priceless"

Jono.  Great post.  I agree with everything that you have said there.  I have worked in and around the UK and International Medical profession for over 30 years and endorse what you say about the driver for some of these type of articles. They are after all humans and in any walk of life there are the full spectrum of individuals displaying good traits and not so good traits. In addition, both my kids are medics and I hope they have the better traits!
Left Birmingham Hip Resurfacing
11th September 2012
Mr Ronan Treacy 54mm head 60mm cup

Ross

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Re: Dr. Su responds to the recent Lancet article
« Reply #9 on: January 05, 2013, 01:15:11 PM »
I had a girl slash friend who was active and 50.  She had no dysphasia, good bone quality, and was never informed about resurfacing.  She said that she did not want to travel.  She was in Nyack NY.  Gave her Dr Su name and number.  Her THR surgeon talked her out of it and told her she would have zero restrictions and a hip that would last a lifetime.  It dislocated at the one year mark while working and now she can not return to work as a nurse and was forced out of the ER. ****** ********

 

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