Runnnig after Hip Resurfacing Comments by Surgeons

[Pat Walter]

I asked a handful of top hip resurfacing surgeons about their opinon on running after hip resurfacing.  The answers are slowing coming in.

[Pat Walter]

Hi Pat,

Thanks for asking about running and other impact activities after hip resurfacing.

What I can tell you about this is that the study referencing a higher failure rate in impact sports involves the Conserve Plus device, not the Birmingham which I use. They are not strictly comparable. The main difference I could see in the Conserve Plus is the presence of a cement mantle (layer) between the femoral head component and the femoral neck. The BHR on the other hand is virtually line-to-line between metal and bone. The Conserve Plus therefore has three layers: metal, cement and bone, where the BHR has two.

Whether that is an advantage has been debated. BHR pressurizes the cement more, driving it deep into the cancellous bone of the femoral head. Critics argue that this may kill of some of the bone. On the other hand, there are no cement loosening failures with BHR, the way there have been reported with other devices, and a higher overall survivorship with BHR. (There are late femoral loosenings due to head collapse, but that is different than head loosening on an intact cemented neck).

Where there is a cement mantle, you do not have intimate contact between metal and bone. The intervening cement has a different stiffness than the metal or the bone, so there will inevitably be differences in relative bending of the 3 layers under load. Cement is also more brittle than metal or bone. Thus, under any loading, there may be relative shear between the different layers undergoing minute amounts of bending and displacement. Cement does not do well under shear loading.

Impact loading in particular, such as running, could be expected to have a greater effect on the more brittle cement than on metal or bone. Of note, I believe that DeSmet in Belgium has modified the Conserve Plus instrumentation to eliminate the cement mantle. Another distinction is the recommendation to cement the stem of a Conserve Plus in cases of femoral head weakness or cyst formation. Any time you cement a resurfacing stem, you off-load the head to some extent, transferring load down the stem to the neck. This will result in "stress-shielding" and bone resorption in the head. BHR users are told never to cement the stem.

I do not plan to change my current advice for BHR patients, which is unrestricted activity 12 months after resurfacing. I believe that waiting 12 months is a good idea, to allow remodeling and healing of the reamed femoral neck, aiming to avoid femoral neck fracture, a common early failure mode. So far, in 1600+ BHR's, I have had only one femoral neck fracture (knock on wood), my case #6 nearly 7 years ago. who was doing leg presses after only 8 weeks.

I think in general people should return to running or other impact sports in a gradual, sensible manner.

The developers of BHR, McMinn and Treacy from the UK, who have 15 years of experience in over 8000 BHR's, also allow unrestricted activity after 12 months.

Peter Brooks MD
Cleveland Clinic

[Pat Walter]

Pat:

Our study (lead author Le Duff - see attached) showed some deterioration after impact post 10 years post implantation but that was with our earliest Conserve Plus technique. However with good bone quality and improved technique the results show no deterioration at ten years. Do not have the 15 year results on those as yet but included are runners, lots of tennis players and others with high impact. I do however  believe that our new porous ingrowth femoral and biofoam sockets will perform better over the long term. They are approved everywhere in the world but in  the US but I use under physicians indication. The performance is spectacular at 3+ years and I expect that impact will have no adverse effect on durability (based on our earlier versions anthem 1980's)

Regards
Dr. Amstutz
Study Dr. Amstutz is commenting about:

Public release date: 8-Feb-2012
 American Academy of Orthopaedic Surgeons

 Excessive sporting activity may impair long-term success of hip resurfacing

Original News Release:

 http://www.abstractsonline.com/Plan/ViewAbstract.aspx?mID=2841&sKey=8f07675f-aadf-4b0b-baed-e7aabc4b0f69&cKey=7c32b727-acd9-44a7-bb88-909c43baf3c5&mKey=BA8AA154-A9B9-41F9-91A7-F4A4CB050945

Classification: Adult Reconstruction Hip
Keywords: Outcomes; Complications; Hip
Author(s):
Harlan C. Amstutz, MD, Pacific Palisades, California, United States
 Michel J. Le Duff, Glendale, California, United States
 Regina Woon, Los Angeles, California, United States
 Alicia J. Johnson, BA, Los Angeles, California, United States
 

Patients should limit activities to maintain hip prosthesis

 SAN FRANCISCO – In hip resurfacing the femoral ball in the hip joint is not removed, but instead is trimmed and capped with a smooth metal covering. Young and active patients with arthritis often choose hip resurfacing over total hip replacement to minimize the risk of hip dislocation, and to preserve the bone for a revision surgery should the primary resurfacing fail. However, the long-term effects of sports on a resurfaced hip were unknown.

In new research presented today at the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), investigators surveyed 445 patients between one and five years after hip resurfacing. The type of activity, frequency and duration of the sessions, and intensity of participation were documented. Over the next 10 years, each patient's hip status was monitored. The mean age of the patients was 48.7 years, and 74 percent were male. There was a correlation between higher activity scores and risk for surgical revision. Other independent risk factors for revision included small component size, low body mass index, and 1st generation surgical technique. Patients with an Impact Score (IS) lower than 50 had a revision risk rate 3.8 times lower than the patients with an IS of 50 or greater. Survivorship for patients with a lower IS score at eight years was 96.4 percent versus 88.8 percent.

Large amounts of high impact sporting activities – such as daily running or tennis– can be detrimental to the long-term success of hip resurfacing arthroplasty. Surgeons should advise patients to limit their physical activity to levels that the device can sustain.




 

[Pat Walter]

Dr Gross reviewed the article (above about running and hip resurfacing by Dr. Amstutz.)  He said with the uncemented component, there is no restrictions. He feels that article pertains to the cemented components.

Lee Webb for Dr. Gross

[Pat Walter]

Pat,

Up to this point I have not been restricting activities on BHR patients after six months. Whether people get back to high-intensity running, biking, or swimming has been left up to the patient.

We only have six years of follow-up and at this point I cannot say that we have done any revisions for loosening. Particularly the young active males, even with high activity levels, have had unbelievably successful results.

I tell my patients postop that they wore the hip out that God gave them so running marathons would likely produce more wear than sedentary activities. I leave it up to patient to determine their own activity level. Dr. McMinn's data suggests that Heat treated cups start to fail at an accelerated rate after about seven years. Maybe the increased running Nd high impact activities would become more significant in those patients with heat treated cups. Some of these patients just won't listen even if you try to convince them to cut down their activities.

Dr. Rogerson

[Baby Barista]

This is really great Pat! Thanks for reaching out to a broad cross section of surgeons. I think these kinds of posts are some of the most beneficial on your site, for people considering hip resurfacing surgery.

[evant]

Thanks Pat.

Always great to hear direct from the surgeons.

[Dannywayoflife]

Thanks pat. I thought that the unique use of cement in the bhr would be the key. The tighter component and the negative pressure caused by the suction vent in the throcanter really drive the cement into the bone. Treacy said it creates kind of a composite. And I believe McMinn calls it micro interlock.

[chuckm]

Resurfacing naysayers won't be very happy reading this stuff. Statistics are like language, you can interpret them any way you want.

Hearing from top resurfacing experts sure does tell a different story than someone's interpretation of a national registry on resurfacing.

I wonder what the registries said about traditional hip replacement for its first 10 years?

Chuckm

[hernanu]

Thank you Pat. It's this kind of insight that makes this site such a valuable resource.

[Pat Walter]

chuckm

At the bottom of this aritlce summary I wrote are the THR stats.

http://www.surfacehippy.info/2012-aoanjr-hip-resurfacing-information.php

If you have time, the original registry information from 2006 is here

http://www.surfacehippy.info/nationalregistries.php

There are no perfect hip replacement devices.  Total Hip, Resurfacing, Cemented, Uncemented, MOM, COM - they all have problems.  The decision is to choose a top surgeon and let them help you find the correct device for you.

Pat