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Author Topic: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012  (Read 7464 times)

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Pat Walter

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THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« on: November 28, 2012, 03:22:20 PM »
Dr. Gross prepared this response and asked me to post.


THE DURABILITY OF HIP RESURFACING

Thomas P. Gross, MD

13 years experience. Over 3000 cases.

For more information: grossortho.com


A recent Article in the Lancet medical journal has criticized hip resurfacing arthroplasty (HRA) as less durable than cemented 28mm total hip replacement (THR). I take exception to the inappropriate conclusion that the authors drew from this highly flawed study.

However, there are two conclusions that can be drawn from this study.  Surgeons, who are inexperienced in hip resurfacing, have more revisions in the short term with resurfacing than if they stick with standard hip replacement. Women have a higher failure rate than men with hip resurfacing. Both of these are old news.

Hip resurfacing has several distinct advantages over stemmed small bearing total hip replacement. The resurfaced hip most closely resembles the natural hip. Biomechanically the hip is stable, most of the bone is preserved and stresses are transferred more naturally to the remaining bone. Near normal function can be achieved, even by impact athletes. Thigh pain  (3-5% of stemmed THR) does not occur in resurfacing. Dislocation is rare (<0.5%), and revision for recurrent instability is extremely rare (0.03%).

The problem is not with resurfacing. The first problem is that two poorly designed hip resurfacing implant systems were released into the marketplace. The second problem is that too many surgeons have dabbled in resurfacing and never achieved enough experience with this difficult operation to get over the learning curve. It is worth emphasizing that the average surgeon volume for resurfacing in the Lancet study was 3.7 cases / year. The results of inexperienced hip-resurfacing surgeons are nicely captured in the Lancet article.

Therefore, the first challenge is to develop more specialist surgeons who can match the current results of numerous high performing hip resurfacing surgeons. The second challenge is to elucidate the underlying reasons why women have more failures with resurfacing and find ways to improve the outcome in women.

My conclusions from this study, the other available data and my personal experience with hip resurfacing are:

•   Most orthopedic surgeons are not qualified to perform hip resurfacing.
•   Very high failure rates are achieved by surgeons who perform an average of only 40 resurfacings / in 7 years (4.6 cases/year).
•   Cemented 28mm total hip replacement has an unacceptably high failure rate in young patients.
•   Hip resurfacing done by specialists in hip resurfacing has a high success rate in young patients.
•   All young patients requiring a hip replacement should be referred to specialist hip resurfacing surgeons. Young patients’ risk of failure is higher if they have a 28mm cemented THA or if they have a HRA by a surgeon who is inexperienced in this operation.
•   If you are a patient who wants a hip resurfacing, choose a surgeon who can demonstrate (in writing) a personal high success rate with this operation.

A recent article analyzing and comparing failure rates of various hip replacement types has recently been published in the Lancet Medical Journal. It finds that the revision rate for hip resurfacing among hundreds of surgeons in England and Wales is higher than the revision rates for cemented 28 mm cemented total hip replacements. Therefore, they suggest that hip resurfacing should be abandoned. They focus particularly on 5 -year survivorship data; the failure rates reported were:

•   Resurfacing, all patients:      5.2%
•   Resurfacing in men:         3.5%
•   Resurfacing in women:      8%
•   Cemented 28 mm M/P THR:      2.8%

I am concerned with the revision rate reported among this cohort of 698 English and Welsh surgeons trying to perform hip resurfacing. My personal experience is completely different than what these British surgeons can achieve.

I have now performed 3000 hip resurfacings since 1999. This is more than 10% of the entire British experience reported on in this Lancet article. I have practiced very limited patient selection. About 2/3 of my patients are men and 70% have osteoarthritis. I do not avoid patients with smaller implant sizes. I have maintained follow-up on 92% of my patients. I keep track of causes for revision as well as complications. My 5-year failure rates are as follows:

•   Resurfacing, all patients:         2.8%   
•   Resurfacing in men:            1.9%
•   Resurfacing in women:         5.2%

•   Uncemented Resurfacing:         1.9%
•   Uncemented resurfacing in men:      0.9%   
•   Uncemented resurfacing in women:   5.1%


How can we explain this significant difference?

Should I accept the conclusions of AJ Smith et al from the British Joint Registry Data published in the Lancet and discontinue hip resurfacing?

I think we can safely conclude one thing from the Lancet article:

Many British surgeons are NOT qualified to perform hip resurfacing and should abandon this procedure.

The problem is, that previous registry studies have shown that young patients have much higher 10-year failure rates with cemented THR. In fact, this same Lancet article quotes a Finnish registry study showing a 28% failure rate at 10 years for cemented THR.

Although the Lancet article confirms that most surgeons cannot perform hip resurfacing well, several high volume hip resurfacing surgeons have demonstrated far lower failure rates than 5% at five years or 28% at 10 years: McMinn, Treacy, Amstutz, DeSmet, and myself, for example.

This indicates that young patients should not receive cemented 28mm THR, they should not receive resurfacing from inexperienced resurfacing surgeons, they should rather be referred to specialists in hip resurfacing who CAN achieve high success rates with hip resurfacing.

Although large registry studies are one valuable source of information for surgeons, it would be foolish to use only registry data to make all of our decisions. There are many shortcomings of registry data:

1.   Only revisions are counted as failures.
2.   Complications are not reported.
3.   Function is not assessed.
4.   Bone preservation is not considered.
5.   Patient activity level and restrictions are not evaluated.
6.   The effect of surgeon skill is disregarded.
7.   Overall effect on the patient’s life is not measured.


Before addressing these issues, I have two other major concerns with this study:

First is their low rate of follow-up. The methods section states the analysis is based on 82% of THR’s undertaken. What happened to the other 18%? This is supposed to be a national joint registry? My data is based on 92% rate of follow-up and I don’t have the benefit of a national registry. This fact alone casts great doubt over the entire study.

Second is their choice of implant inclusion. They did appropriately remove the DePuy ASR implant from analysis (recalled by DePuy in the US 2010). But the Zimmer Durom was another failed implant, which was removed from the US market in 2008 because of a high failure rate. Why was this implant not removed from this analysis?

Now we will critique the other shortcomings of registry studies listed above:

1.   Because registry studies only count revisions as failures, it is not known which group studied has more unrevised but failed implants. If a patient has an implant has a loosened painful implant but is not revised, this is still considered a success by the registry. If a patient has suffered three dislocations but has not been revised, this is still considered a success by the registry.

2.   Dislocation is the most common complication in THR but almost never happens in hip resurfacing. A recent randomized controlled study from Australia has shown the dislocation rate of 28mm THR to be 5.2% within the first year after surgery. The most common reason for revision for THR in the US is dislocation. It accounts for more than 20% of all THR revisions in the US. My rate of dislocation for HRA is < 0.5%.  Only 1/3000 (0.03%) have required revision for this problem.

In HRA, bearing size is the same as the natural hip and the normal hip biomechanics are closely reproduced, leading to normal hip stability. After a 6-month healing period, patients can bend their hip how they like and engage safely in all sports including gymnastics and kayaking. This is simply not possible to do with a 28mm THA.

But the Lancet article suggests that resurfacing should be abandoned? This is an ivory tower conclusion that ignores the desires of many younger patients sidelined from an active lifestyle or from physical work because of an arthritic hip. These young people would be unable to return to their desired activities after a standard THA. Apparently the Lancet authors have not considered this fact. A 28mm cemented THA simply does not meet the needs and desires of many young patients. It does not compare to an HRA.

3.   Patients with THR are usually not able to resume as high a level of function as those with HRA. If they do manage to return to impact activities, they have a high rate of implant failure. HRA only has a higher rate of implant failure at extreme levels of activity, and most of those are from failure of femoral cement fixation.

Functional potential is much greater after HRA. If a patient wishes to golf, walk or even use an elliptical it is doubtful that they would notice the difference between a HRA and a THR. But if they are interested in physical work or impact sports they are much more likely to resume these after HRA. 4/5 published gait studies have shown normal gait with HRA, but abnormal gait with THR. 2 large comparative survey studies by Barrack and Noble have shown a much higher activity level achieved by young people if they had an HRA compared with THR. In a 15-year comparative study Argenson has recently shown that THR had a 6.5% loosening rate in low activity patients and a 20% rate in patients with a high UCLA Activity score (partaking in impact sports). Amstutz was unable to show any difference in implant survivorship after hip resurfacing at 10 years when using the UCLA activity score, but could show a difference when using a much more rigorous hip impact score (3.6% vs. 11.2% failure at 8 years; 70% of failures were cement loosening of the femur).

Resurfacing clearly allows better function and tolerates higher level of activities. The primary remaining challenge is failure of fixation of the cemented femoral component. I predicted this 12 years ago and therefore have pursued uncemented femoral fixation. The results at 5 years are promising, but not yet conclusive.

4.   Bone preservation for future revision surgery is still an important consideration in young patients needing a hip replacement. The amount of bone removed from the acetabulum in the original THR is similar to that for HRA. But on the femoral side much less bone is removed during HRA than in THR where the entire head and half of the femoral neck are removed. Removing a stem from inside the femoral canal can lead to further bone destruction at the time of revision of a THR. Many patients are justifiably not sufficiently confident in the durability of THR to allow surgeons to amputate their femoral head and neck at a young age. But the authors of the Lancet article do not consider bone loss.

5.   Patients that have an HRA with a cemented femoral component can safely participate in impact sports, but should refrain from extreme impact activities such as running long distances. Patients with uncemented resurfacing are not restricted from any activity after 1 year after surgery. Because the hip ligament heals after 1 year, full unrestricted range of motion is allowed for all HRA. Neither impact activity nor extreme bending is advisable for cemented 28mm THA.  40% of my patients choose to participate in impact activities after HRA. When a registry study compares THR to HRA can they possibly be comparing equivalent patient populations?

6.   HRA is widely acknowledged to be a more complicated operation to master than THR. There are few if any orthopedic residents that learn this operation during their training. If a surgeon is interested in resurfacing, he has to mostly learn it himself. Numerous studies have indicated that the learning curve is long. In a study of my first 373 HRA, my failure rate continued to fall after the first 200 cases. The Lancet study reports on 26,119 HRA done by 698 surgeons over 8 years; an average of 37 cases per surgeon or 4.6 cases/surgeon/year. They claim to account for the “learning curve” effect. This is a ridiculous claim when most British surgeons in this study have performed fewer than 100 HRA.

7.   In a recent study evaluating the same English and Wales registry, McMinn has found that life expectancy for men after HRA is greater than after THR. Results were adjusted for age, gender and level of health but not for activity. There are several possible explanations.

•   Perhaps patient populations in the British registry who have HRA are not the same as those that have THR despite the fact that age and health status were controlled. If this is true, how can the Lancet article then compare failure rates between two different groups of patients in a meaningful fashion?
•   If young patients who receive HRA have a higher functional level than THR patients, perhaps the positive effects of exercise account for their lower mortality?
•   Perhaps there is something in the technique or materials of a THR that are deleterious. For example, fat embolism occurs with femoral preparation in THR but not in HRA. This may cause previously unrecognized permanent cardiopulmonary dysfunction. Critics of metal on metal bearings have long speculated that cobalt and chromium released by HRA bearings may cause cancer or other ill effects. The potential cancer effect has long been disproven with studies up to 30 years. Now it appears that patients with these metal bearings actually live longer! It will be interesting to learn why patients with THR have a shorter life expectancy than patients with HRA.


In summary, the conclusions of the Lancet study are based on a very limited and superficial analysis of THR vs. HRA. The Lancet study only illustrates that a patient should not allow an inexperienced hip-resurfacing surgeon to perform his/ her operation. It confirms what many other studies have already shown: that women have a higher failure rate than men with HRA, but it adds no new information on why this may be true. There are numerous advantages of resurfacing that are simply not evaluated by this study. The Australian hip registry shows a better survivorship for young men with HRA. Young active people are not able to resume their desired lifestyle with THR.

Young sporting people or physical workers should be advised that THR will relieve their pain but will not safely allow them to resume their lifestyle. Surgeons who are not experienced with HRA should not attempt to perform this operation without warning their patients that their failure rate is probably much higher than that demonstrated in specialist centers. Data from this Lancet study suggests that young active patients should be referred to specialist centers for hip resurfacing with demonstrated low failure rates with this procedure. In England, for example, a vast difference in outcomes is seen between Oxford and Birmingham. More than with most other procedures, it is critical for the patient to do their homework before undertaking HRA and to select a surgeon who can demonstrate a high success rate with this operation.



References:
1.   Ollivier et al; CORR 2012. Does Impact sorts Activity Influence Total Hip arthroplasty Durability?
2.   LeDuff et al; JBJS Am 2012. The relationship of sporting activity and implant Survivorship After Hip Resurfacing.
3.   Smith et al; The Lancet 2012. Failure rates of metal-on-metal hip resurfacings: analysis of data from the National Joint Registry for England and Wales.
4.   McMinn et al; British Medical Journal 2012. Mortality and implant revision rates of hip arthroplasty in patients with osteoarthritis: registry based cohort study.
5.   Gross et al; Journal of arthroplasty 2012 Hip resurfacing with the Biomet Hybrid Recap-Magnum System
6.   Gross et al; Journal of arthroplasty 2011. Clinical Outcome of the Metal-on-metal Hybrid Corin Cormet 2000 Hip Resurfacing System
7.   Brekke, Noble et al; ISTA 25th Congress Sydney Australia 2012. Patient Function and Satisfaction After Large Head Total Hip Arthroplasty versus Hip resurfacing.

« Last Edit: December 11, 2012, 07:34:15 PM by Pat Walter »
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hernanu

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #1 on: November 28, 2012, 04:10:43 PM »
Good golly, it's like watching an adult scold a wayward teen.

So this was posted to the Lancet?
Hernan, LHR 8/24/2010, RHR 11/29/2010 - Cormet, Dr. Snyder

obxpelican

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #2 on: November 28, 2012, 05:45:16 PM »
Dr. G taking off the gloves,   GOOD!    ;D




Chuck
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Dannywayoflife

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #3 on: November 28, 2012, 06:37:58 PM »
Really good read!
Train hard fight easy
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Pat Walter

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #4 on: November 28, 2012, 07:49:13 PM »
I don't think it was posted to the Lancet.  Dr. Gross wants to support hip resurfacing and have good outcomes.  Many of the top surgeons are trying to post information to correct all the negative media and other small medical studies.

Pat
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patrick_d

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #5 on: November 29, 2012, 12:00:56 AM »
Dr. Gross's passion for HRA is amazing.  He has completely dedicated his life to improving and optimizing HRA products and surgical procedures all to the benefit of his patients.  This article makes that crystal clear.

Prior to meeting Dr. Gross for the first time before my surgery I was pretty certain of skill, passion, and dedication (from reading his papers and watching his videos), but when I finally met him 3 months before my surgery I knew there was no doubt.  Anyone in the USA considering HRA would be very well served to take the time to meet Dr. Gross for a consultation visit.
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Marco Polo

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #6 on: November 29, 2012, 02:53:33 AM »
Smack down!  It's great that we have the benefit of the skills and experience of dedicated surgeons like Dr. Gross and others that have made this procedure a focus of their medical practice.  This Board performs a valuable service by making this information available to patients considering hip resurfacing as an option.  Pat, thanks for posting.
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Dee Dee

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #7 on: November 29, 2012, 04:59:46 AM »
Wow what a read!
The work that Dr. Gross' must have done in drafting that response to the Lancet article is absolutely tremendous.  The passion for his work is obvious.  I can appreciate why he would make the challenge.  He has poured a lot of time and energy into perfecting the HR and thereby helping patients.  All the experienced surgeons (as well as us hippies) will benefit from his response, because accurate education is truly important.  I am glad Pat posted. 
Right HR  5-23-12  Dr. Gross
Left HR 12-5-12 Dr. Gross

Baby Barista

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #8 on: November 29, 2012, 05:02:39 AM »
If the debate about hip resurfacing were a UFC fight... Dr. Gross just delivered a ferocious arm bar to the naysayers. Well done good sir, well done.
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Tim Bratten

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #9 on: November 29, 2012, 02:45:51 PM »
I was actually flabbergasted when I first looked at the Lancet article and saw they were recommending that resurfacing not be done in women because a 28mm cemented plastic on metal THR had lower five year revision rates. Basing that conclusion on the given comparison was so ridiculously weak that I have a hard time imagining how it got published in a reputable journal.  Glad to see Dr. Gross took the time to give the authors a well deserved slap down
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Tin Soldier

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #10 on: November 29, 2012, 09:37:56 PM »
Not only is Dr. Gross an expert in HR, he's an expert in epidemiology and analysis of ALL the data.  This is excellent.  Thanks Pat.

It's nice to have a kick-ass surgeon like Gross stand up to the docs that wrote that article.  Its apparant that he's advocating for HR not just for the fight or to show everyone he know he's stuff (which he does), but also for everyone one of us who would have faced pain for another 10 to 20 years before going with the THR and who can now enjoy the same active lifestyle we always had.  His statement quoted below, pulls at my heart strings.     

Quote
This is an ivory tower conclusion that ignores the desires of many younger patients sidelined from an active lifestyle or from physical work because of an arthritic hip. These young people would be unable to return to their desired activities after a standard THA. Apparently the Lancet authors have not considered this fact.


Well done Dr. Gross!
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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #11 on: November 30, 2012, 12:59:13 AM »
I am very glad that this site steered me toward Dr. Gross!  I've been able to resume all my previous activities and my biggest decision for a day off from work for tomorrow is whether to go downhill skiing for the 1st time in 1/12 years, or break out the snowshoes for a winter ascent of one of our Adirondack "high" peaks- not once worrying about my right hip!

Thanks to all of you and especially Pat for the great job and support.

Steve
52 YO Rt Hip Biomet Dr. Gross, 10/24/11

hippy hippy shake

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #12 on: November 30, 2012, 01:50:00 PM »
I wholly agree with the thought process that we should use the experienced surgeons' revision rates for evaluating the effectiveness of hip resurfacing. 

However, as I am still researching this, I would also love to see a similar calculation for THA.  From my research thus far, it seems like the failure of many of THA's is due to incorrect placement angle of the cup.  So it only seems fair to compare the revision rate of the high volume resurfacing surgeons to the revision rate of the high volume THA surgeons.  Of course with selection by age and gender as well.

While I recognize that the THA is relatively simple surgery compared to resurfacing, it seems that one of the most important components impacting the revision rate is identical - proper cup placement.


I had hoped to have a less controversal entrance into this forum, but I am trying to sort out the information, and there seems to be a piece missing.   
(FYI, I have my introductory appointment with Dr. Su in January.)

Thanks!   
Bilateral BHR 4/18/2013
Dr. Su

Bryan712

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #13 on: November 30, 2012, 02:41:28 PM »
I find it interesting that way he dissects the data and points out all of the inconsistencies that lead the Lancet study to its flawed conclusion.  I am still a newbie 11 days out from my BRHR, but several things that Dr. Gross pints out are the reason I chose this route.

1) Activity level- I have 3 children 4,7, and 11. They are all involved in sports, football, soccer, baseball etc. My hope is to resume my activity level I had previous to the pain from severe bone to bone osteoarthritis. Not that I want to necessarily be in these impact sports myself, but to participate with them in practice in the front yard and at the park etc.

2) My own Health- At 43 I am very active riding my bike, working out at the gym etc. I want to continue these activities and as is pointed out at the end of this response from Dr. Gross. A THR at this age will more than likely lead to a revision and additional bone loss. How can I stay active and healthy thus avoiding weight gain, heart, possibly diabetes (runs in my family) and other negative effects of being inactive.

3) Normal Gait- Don't know bout ya'll (I am from Alabama) but I am not interested in an abnormal gait at 43, not to mention to me it makes common horse sense that a 44mm ball and socket for a 210 lb body beats a 28mm any day.

Just my thoughts..

hernanu

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #14 on: November 30, 2012, 05:24:36 PM »
I wholly agree with the thought process that we should use the experienced surgeons' revision rates for evaluating the effectiveness of hip resurfacing. 

However, as I am still researching this, I would also love to see a similar calculation for THA.  From my research thus far, it seems like the failure of many of THA's is due to incorrect placement angle of the cup.  So it only seems fair to compare the revision rate of the high volume resurfacing surgeons to the revision rate of the high volume THA surgeons.  Of course with selection by age and gender as well.

While I recognize that the THA is relatively simple surgery compared to resurfacing, it seems that one of the most important components impacting the revision rate is identical - proper cup placement.


I had hoped to have a less controversal entrance into this forum, but I am trying to sort out the information, and there seems to be a piece missing.   
(FYI, I have my introductory appointment with Dr. Su in January.)

Thanks!   

Hey, welcome HHS, that's not controversial, we're all interested in digging out the truth. You should do as much research as is necessary for you, since this is an important and private decision.

I agree that it would be good to see the same type of research done for THRs, but since we're focused on resurfacing and it has been under attack for being dangerous, while the truth is (in my opinion) that it serves the purposes intended and is as safe as the alternatives in experienced hands. Its benefits are the ability to return to your previous activities with more success.

Someone who does four HRs per year is obviously not committed to excellence and should be avoided. I wouldn't take my car to a mechanic who fixes cars four times per year, how much more important is the upkeep of your body and especially such a critical junction in your frame.

I would imagine the same is true for a THR, that you want as much experience in the career of someone who is restructuring your hip. As Dr. Gross mentions, though, HR is a more demanding procedure which requires more skill for good outcomes.

Keep up your research until you're comfortable that you have the information you need. As Bryan points out, it is good to see the flaws in logic that may sway your opinion; the only way you'll make a good decision is by seeing the underlying truth, once you remove the screens of bad logic and sensationalistic opportunism.

(In my opinion, of course).

Hernan, LHR 8/24/2010, RHR 11/29/2010 - Cormet, Dr. Snyder

Dannywayoflife

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Re: THE DURABILITY OF HIP RESURFACING by Dr. Gross 2012
« Reply #15 on: November 30, 2012, 07:08:13 PM »
There are more ways a thr can fail over a HR. One of the huge plusses to HR is no stress shielding. This is a longterm problem for THR as shown by wolfs law the force transmitted with a THR is differen and the bone density will lower. With a HR bone density can increase
Train hard fight easy
LBHR 10/11/2011 Mr Ronan Treacy Birmingham England
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Rbhr 54mm head 60mm cup 12/02/15 Ronan Treacy ROH Birmingham England
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