Looking for any advice and/or feedback

[gerard]

Me:
Male, 47 years old. 5’7” and 165 pds. Diagnosed with osteo-arthritis in the right hip 4 years ago (2009)
I have been a very active person leading up to the diagnosis. Since getting the bad news about my hip my ability to “get out there and do stuff” has been greatly curtailed. I also work as a soccer coach and the hip has become more and more of a problem doing my job.

I have heard all the positives about the resurfacing but recently I have heard and read some of the horror stories emerging about metal on metal resurfacing and the adverse reaction the body may have to the implant.

My recent visit with my Doctor (Nov 2012) answered a lot of questions but also raised quite a few. I had pretty much decided about going forward with surgery and wanted the Birmingham Hip Resurfacing for all the benefits of returning to an active lifestyle, bone retention, quick recovery, etc. that it offers. I went into the meeting with my Doctor feeling that it was time to begin setting a date for surgery.
 
Now I’m not so sure?

My doctor was definitely steering my away from resurfacing and towards total replacement. The information I received from my Doctor in a nutshell:

1)   ALL metal on metal hip implants are now considered problematic due to metal ion sensitivity? So not just the Depuey.
2)   The odds of returning to an active life style are about the same whether I have the resurfacing or the total replacement.
3)   The problems associated with the total hip replacement are significantly less than with the resurfacing?
4)   The number of Resurfacing procedures being performed has greatly dropped with the problems associated with metal sensitivity.
5)   My body size (about 5’7”) is on the lower end for the socket (in a BHResurfacing procedure) and might cause a problem?

My Doctor said he would do the Birmingham Resurfacing BUT wanted me strongly to consider the problems with metal ion sensitivity. I also felt that he would prefer the total replacement procedure instead of the resurfacing.

I do not doubt the information I received from my Doctor, but I now am very unsure about which procedure to get??
So?? I mustn’t be the only one wondering about what to do and which surgery to have??

Are there other people out there hearing the same:

Resurfacing    - Return to active life about 76% positive results.
         -Ion (metal on metal) problems?
         - Problems increasing and not fully understood yet??

Total Replacement    
                        - Return to active life about 75% positive results.
                        - Problems occurring in less than 5% (something like that??) and a greater track record.

Any feedback would be much appreciated

[OtterDriver]

Hello gerard -

I'm sure lots of others on this site will chime in here shortly on this topic...so standby!

Confirming your surgeon actually does hip resurfacing?  He certainly doesn't sound like a proponent of the procedure!  Do your homework and get multiple opinions.  Study this site in great detail.

I've got nine years, seven inches and about thirty pounds on you.  Had my right hip resurfaced about a year and a half ago and would not hesitate to do it again if the need presented itself!

I was charging up steps at SEA/TAC Monday...bypassing the Escalator...and thinking how great it was to be free of pain in the process.

Good luck in your search for answers!

Bruce

[trgcfrg]

Gerard,

Good luck in your research and decision process. I had many of the same questions you had about THR vs. HR and concerns about metal on metal wear issues, and my situation is similar (38 year old male, 160 pounds, 5' 11"). From my research, I believe four things are true:

1) Hip resurfacing surgery is more difficult to do than THR surgery and results are significantly better with experienced surgeons (i.e. someone who does has done at least 500 HR surgeries and does the procedure frequently). Implant placement is critical, and inexperienced surgeons have many more problems with this than the most experienced surgeons do. Surgeon choice is probably the most important decision for hip resurfacing surgery.

2) Hip resurfacing patients typically have better functional results vs. THR patients (e.g. more natural walking gait, fewer revisions with higher activity rates). Read the great article by Dr. Gross that Pat has posted to this site (http://surfacehippy.info/hiptalk/hip-resurfacing-still-an-excellent-option/the-durability-of-hip-resurfacing-by-dr-gross-2012).

3) Metal ion complications with well-placed hip resurfacing implants are rare (Dr. McMinn's stats are 0.3% http://www.mcminncentre.co.uk/metal-ions-questions-answers.html, for example)

4) Younger males tend to have better implant longevity with hip resurfacing vs. THR. See the "Osteoarthritis, Male patients under 55 years old" implant survivorship graph (http://www.mcminncentre.co.uk/metal-ions-questions-answers.html) from Dr. McMinn (one of the pioneers of hip resurfacing) as an example, but other registries seem to bear this out as well. Given that I'm younger, I like the idea of retaining more bone should a revision to THR be necessary down the road.

Based on my research, I decided to move ahead with hip resurfacing surgery. I just got my first of two surgeries 2.5 weeks ago with Dr. Pritchett in Seattle. So far it looks like the surgery has gone well, the implant placement is good, and I'm pleased with the early progress of my recovery.

I would suggest you first consult with a more experienced hip resurfacing surgeon (Pat has a list of the best doctors on this site, several will review your X-rays and offer consultation via e-mail for free) to find out if implant sizing or other issues would be an issue for you.

Good luck on your research and your decision!

[Tim Bratten]

Hi Gerard
The post by trgcfrg is well constructed and true.
The answers to your questions are:

1) A well placed HR very rarely results in problems with metal ions. There are a small number of people (as I recall De Smet told me roughly 1 in a 1000) that exhibit a special sensitivity to metal ions.

Compare this to metal on plastic THR in young active patients: one of the main causes of revision is osteolysis which is a destruction of the bone from plastic particles worn off during activity. This problem is well documented.

So which is better?

2)  The answer to this depends a lot on what systems you are comparing. When De Smet began HR he was also placing ceramic on ceramic THR with a 28mm head. Follow ups showed that the HRs were doing significantly better in terms of functionality and satisfaction (reference: http://www.healio.com/orthopedics/hip/journals/ORTHO/%7BB4E3C3E6-EAC3-4B23-BC22-9EC9B2EDD0FD%7D/Primary-Ceramic-on-Ceramic-Total-Hip-Replacement-Versus-Metal-on-Metal------Hip-Resurfacing-in-Young-Active-Patients). Since then he has greatly improved his THR system (he uses ceramic/ceramic with heads up to 48mm) and is much happier with the results, but he still told me he felt that half the hip patients would benefit from HR.

One problem with THR is that when small heads are used (e.g. 28mm) then dislocation is a major cause of revision so the patient's activities are typically restricted (no bending in certain ways, etc.)   

3) Absolutely false, although it is imperative that you have your HR done by an expert in HR (I found that out the hard way).  In other words: if you are hip surgeon trying to start out in HR then it may be true that "the problems associated with the total hip replacement are significantly less than with HR" because the procedure is challenging to master, however if you are a patient going to an experienced HR surgeon then the statement is absolutely false.

4) There are less HRs being done overall, but it seems to me the reason is that many problems were caused by non-experts who dabbled in the procedure. On the other hand, the specialists in HR are well booked up in advance and are doing as many procedures as ever.

5) Small hips definitely make the procedure more difficult, even for the best surgeons (but hip size, not height is the relevant measure). So yes, there are more problems associated with women/smaller hips. When it comes to this, all I can say is contact one of the expert HR doctors (e.g. De Smet) and ask for their opinion about the possibility of HR for your particular conditions.

As a final comment: since your doctor is not convinced about doing the HR I would DEFINITELY NOT let him do it. If you are totally set on the doctor , then let him decide what procedure he is best at.  But I think you should also be well aware of the various problems associated with different THR systems in young patients. I found out the hard way that there are some really good hip surgeons out there doing some pretty amazing work and that it's worth the effort and cost to try and seek them out.


Good luck!
Tim Bratten

[chuckm]

Girard, I have a friend who had a total hip replacement about four weeks after I had my hip resurfaced. Mine November 30th 2012 and his around new year. I went to a specialist in NYC to have mine done and he went to the doctor his insurance told him to.

I am now playing pick up soccer and he is still limping. I coach soccer and will play competitive in another month. It feels like my normal hip.

Chuckm

[Dannywayoflife]

Girard my advice is to go see a TOP surgeon who uses a PROVEN DEVICE and your chances of regaining your life are massively in your favour. Do not go to an inexperienced surgeon!!!!

[maxx6789]

we will have different goals from life and hip surgery!! being also 47, the two things that convinced me were:

1) in terms of return to activity, i sometimes hear with a THR you could be as active as with a resurfacing (no one ever says you can be more active with a THR). one THR surgeon told me i would not be able to return to surfing or snowboarding with his THR (that might have been an extreme position even for a THR). since my bilateral BHR, i both surfed and snowboarded this year and felt great.

2) the "bone-conversing" difference was huge for me and key in my final decision. regardless of how good your device is, at the age of 47, chances are good that we will need a revision eventually. with hip resurfacing, the typical revision is to a THR. with a THR, the typical revision is to a much larger THR (i have seen the size of these and they are large!!).

as many will say ... i believe an experienced, top surgeon is probably the most important piece of the puzzle.

good luck with you, your search, and your hip!!

[Miguelito]

Hi Gerard. Ultimately you are going to have to decide for yourself if you want HR or THR. The people on this site (myself included) are overwhelmingly pro HR. I don't think there are many doc's out there who are agnostic as to device; they are probably going to do either all THR's or all HR's (with de minimis crossover in special circumstances). So after you decide which device you want you then have to pick out a surgeon based on your choice.

I know, it probably shouldn't work that way. I was sent to a doctor at the New England Baptist who supposedly did both. He didn't. He was very anti-THR. Worst medical experience of my life. I was very disillusioned afterwards, but it turned out to have a silver lining as that was the impetus I needed to go out of town (Boston) and travel to one of the acknowledged experts at HR (Dr. Gross).

Mike

[hernanu]

Hi Gerard, you've gotten a lot of good feedback supported by good data.

Some comments:

Now I’m not so sure?

My doctor was definitely steering my away from resurfacing and towards total replacement. The information I received from my Doctor in a nutshell:

1)   ALL metal on metal hip implants are now considered problematic due to metal ion sensitivity? So not just the Depuey.

I heard this from two surgeons that I went to before I found my surgeon. It is an opinion not backed by data. The percentage of total problems caused by metal ion sensitivity is about 8 percent. So that means of all causes for revision as identified by the Australian registry, which is the most extensive study of both THRs and HRs available, 8% of those were caused by metal ion sensitivity.

That includes all procedures and devices, both the Depuy and Duron devices since recalled are in that study, yet the failure rate was still 8% of failures . The overall revision rate over the span of ten years was about 7 percent for all HRs. This included patients who may not have been good candidates, who did not follow proper procedures, whose surgeons had low experience, skills or capabilities.

So the failure rate due to metal sensitivity is 0.08 X 0.07 = 0.0056 or 0.56 percent over a ten year period. The rate of revision for HRs over a ten year period due to metal sensitivity is thus 1/2 of one percent. In the largest study available for us to use.

So I'm not sure where the problematic comes from. If you choose a good experienced surgeon, your odds go up dramatically, which I'm sure you will see if you get in touch with some of the better HR surgeons.

Another thing the study found is that once a surgeon does above 200 surgeries, their revision rate drops greatly. It just makes sense for a more demanding procedure that the surgeons that do many and do them often are more successful. You need committment for this to be a success.

2)   The odds of returning to an active life style are about the same whether I have the resurfacing or the total replacement.

The odds are good for both if you have large head THRs. The smaller heads, as Tim has pointed out are restrictive in lifestyle, since you are at risk for dislocation that is not present with the larger head sizes.

I believe that HR is better for younger active people, since you keep more bone mass. In the case of a future THR revision, which we all face the possibility of, more bone mass will be present to support the procedure. Of course we all hope for no revision needed.

3)   The problems associated with the total hip replacement are significantly less than with the resurfacing?

THR has its own issues. Especially for younger, more active people.

4)   The number of Resurfacing procedures being performed has greatly dropped with the problems associated with metal sensitivity.

I think (this is just me, not Pat) that the issue has shaken the tree and removed the dilettantes. The people who are skilled, remain and thrive are the people committed and take pride in producing good results in their patients. It has been a backhanded advancement in that the people who "will do it if you insist" are out of the business. I'd prefer that they stay out, but it is also a byproduct that they will bad mouth the procedure.

I don't have any problem with good, fact based criticism. It is giving unsupported opinions to good people in need that irks me.

5)   My body size (about 5’7”) is on the lower end for the socket (in a BHResurfacing procedure) and might cause a problem?

Smaller people do present a surgeon more issues in the overall scheme. As Tim pointed out, the size of the hip more than height is the challenge. That does not mean that smalller people are not successful, just that you need a skilled surgeon.

....

Are there other people out there hearing the same:

Resurfacing    - Return to active life about 76% positive results.
         -Ion (metal on metal) problems?
         - Problems increasing and not fully understood yet??

Over a ten year period in the best accumulation of results, the amount of HRs that were not revised (one measure of success) was 93 percent. Revisions due to Ion problems were 0.5%.

Nothing is ever fully understood, but statistically I think we have a good measure here.

Total Replacement    
                        - Return to active life about 75% positive results.
                        - Problems occurring in less than 5% (something like that??) and a greater track record.

I think this also doesn't give THR enough credit. Check the results from the Australian registry (don't have those at hand). There is a longer track record, only because HR has been around for less time.

It's like saying that cars are not a proven method of transportation since they have not been around as long as a horse and chariot.

THR and HR both provide good services for their proper targets. I have two HRs and have returned to a very active, happy life. Will I have problems in the future? Maybe. If so, I am ready for it, but I am in the place I expected now and would not give back the last two years for anything.

Any feedback would be much appreciated

Gerard - you are asking the right questions. Many of us faced the same reaction from some surgeons and went through anyways. Get more opinions, and definitely if you want good results from an HR, find another surgeon who is not reluctant.

You want a good, strong surgeon who has done many and does many every week. There are a good number of those, but you have to be willing to find them.

Good luck.

[Dannywayoflife]

Excellent post by hern there as usual! On the 5'7" thing I'm only 5'9" tall and I got the second biggest device available. Are you small boned?

[RobinK]

Hi, Gerard.
I can't add much to what's already been said, except

Please, please see a surgeon who specializes in BHRs before you make your decision. Make your concerns known.

I'm 5' 6.5" and 147 lbs female. I received a 44mm head and a 50mm socket.

Good luck with your research.

[gerard]

Thank you to all who replied to my post, I really appreciate it – lots to think about and consider.

The first thing I really need to do is get second, third, forth opinions on my hip from other doctors.

Quite a few replies talked about considering the fact that if the doctor is leaning towards one procedure and I am leaning the other way, then we might not be a good match for one another. I did feel like my doctor wasn’t fully invested in resurfacing. If I ultimately decide to go that route and have the HR I should find a doctor who fully behind that decision.

I am located in Madison, Wisconsin so there are some different options for hospitals in town. The Surface Hippy site does mention Dr. John S. Rogerson (680 resurfacings) at Meriter hospital. I will try and get a consult with him. If anyone has any info on Dr. Rogerson, thanks in advance.

In answer to some questions and replies:

“otterdivers”. My surgeon said he WOULD perform a resurfacing if that’s what I wanted, but wanted me to seriously consider the THR. And that would be his suggested procedure for me.

“trgcfrg” suggested there might be some doctors who would look at x-rays/consult via email. If anyone can point me toward free opinions and/or doctors who might have a look at my x-rays etc. that would be great. My insurance is not the best and, like everyone else, I am concerned about the cost.

“Dannywayoflife” asked about being small boned. My doctor didn’t mention that I was in anyway small, or for that matter, big boned? He did mention that the socket cup size would be the second to smallest size. That particular question kind of mystified me i.e.: if the socket implant would be the second to smallest size, why would that be a problem?

Thanks again for everyone’s advice and comments.
Gerard

[Miguelito]

If you send Dr. Gross a copy of your x-ray and a filled out form from his website he will call you up within two weeks (I think) to discuss. No charge.

His website is easy to find (he is in Columbia South Carolina). It is a good resource for information whether you become a patient of his or not. It may also have info as to whether or not he accepts your insurance. Or you could call his office.

Mike

[Marco Polo]

Gerard:  Dr. Rogerson in Madison is outstanding and he will consult based on mailing a copy of your X-rays.  I seriously considered him because he is very experienced and has an excellent reputation, but he did not accept my insurance. I, and several other hip resurfacing patients on this site, also had very positive experiences and outcomes with Dr. Craig Della Valle at Rush Hospital in Chicago.


Regarding the size of components, larger sizes have a better track record on the national registries that track revision rates over time.  That is not to say, however, that resurfacing cannot be successful in smaller boned patients.  In my view it just makes it even more important to have the surgery performed by an experienced surgeon because the margin for error is less.

All the best,

[Tin Soldier]

lots of great posts and I think OtterDriver started off the responses in the right tone "lots of folks will chime in shortly".  As you can see us Hippies have a fairly strong opinion about the non-experienced HR surgeons.  I don't have much more to add other than Pritchett told me that I would probably be on my way to destroying my femurs with the combo of THR and soccer.  The HR is designed for the side-to-side cutting, quick fast stops and turns, lateral motion,...  The THR has more trouble with that due to the THR stem warbling it's way out of the femur.  Hern or someone else probably mentioned that already.

Being a soccer coach and wanting to return to soccer, I'd highly recommed focusing on the HR as your option.  I'm 5'7"  and both of my BHRs seem to be working great and I'm playing soccer at a 40 yr old competitve level (that means I have very little patience for the rough young players, but that doesn't stop me from throwing a CoCr hip at them once in awhile).  I'd play recreatioanl, but apparently in this town, that doesn't exist.

I'm pretty sure Pritchett would look at you images for free.  He might call you also and discuss.   

BTW - I'd also recommend going with a surgeon that does HR mostly, not a THR surgeon who will do an HR if you ask for it.  Rogerson sounds like the right guy in your area.  There's a few of his hippies here and I think Pat has an interview with him posted int he interview section.