"Ideal resurfacing candidate" - Any reason to do THR instead?

[jsblock11]

Got thrown a curveball by my Dr. at the pre-op appointment. Despite being a "ideal candidate" for BHR as stated by my surgeon - 6 foot 2, 38 year old active male with seemingly strong bones, my surgeon's view is that a THR would be a good option for me as well, and maybe even preferred (though he wouldn't confirm whether one or the other would be better for me), since I'm active (hiking/backpacking/biking/yoga) but not a marathon runner or hardcore basketball player.

I was a bit surprised as I thought it would be a no brainer for me to choose the BHR over a total replacement, especially considering Dr. Ball is very experienced with resurfacing. From what I could gather he gave me the impression the THR would be just as durable as BHR for me, with the only pro for BHR being that I preserve more bone but in turn inherit the possible risk of inflammation/pain in the soft tissues due to metal ions over the years.  Of his bilateral patients who've had BHR on one side and THR on the other, ~70% have preferred the THR.

 I'll probably get a biased answer toward resurfacing on this website, but would any of you have any reason to have a THR rather than a BHR, assuming you are a perfect BHR candidate with a skilled surgeon?  I'm a little scared now and wondering if I should just wait it out longer, since I can still hike and ride a bike without trouble. He's definitely a Dr. on the bleeding edge of the hip field in general so it has me wondering if the tide will be turning away from resurfacing and more toward the newer, more durable THR devices? So confused!!

[Quig]

Confused? Welcome to the club! It's a helluva big decision and you're doing your homework and evaluating your options. Good job. It's not easy.


I looked into Dr. Ball prior to my surgeries and remember being fond of him and impressed with his resumé. If he's who you've decided to go with I'd certainly take his suggestions seriously. There are many good options for replacement and in my humble opinion the only place resurfacing has a huge advantage is conserving more bone and loading the femur more naturally. Going to someone with Dr. Ball's credentials, I don't think you can go wrong. Good luck!

[blinky]

I'm with Quig on the two big advantages. I'd add that there is a study out there that says BHR patients are more active and happier with their new hips than THR patients. I can't remember what factors were taken into consideration in that study, like if it was factored out that BHR patients are richer or better educated or younger or more active. (I worry about a selection bias in the study. Very active people seem more likely to have ferreted out the BHR option.)


Why have THR? I have wondered if THR patients would have more choices for a revision surgeon, should that become necessary. The number of BHR docs has contracted, but many orthopedic surgeons can do a THR. I assume that more docs do a THR revision. (This could change. Apparently there are some new, non metal resurf devices coming down the pike. If they are successful, then I bet the number of docs doing resurfacing will increase and then you'd have a greater selection of revision docs if you should need a revision.)


Best of luck making the best choice for you.

[petemeads]

I have a BHR from 3 years ago and a THR that is 5 months old - I should be able to give you clear guidance in a couple of years!
Seriously, I intended to have a second BHR because the benefits seem very obvious despite the small risk of metal sensitivity, but my bone quality was not good enough (femoral head broke during surgery) so I got a Zimmer ceramic/ceramic THR as the next best thing. During my recovery I have walked 320 miles, run 85 miles and cycled 1,010 miles. The THR leg still objects a bit to running but is otherwise fine and as strong as the other. I do worry about the stress-shielding effect of the stem in my femur and the potential loss of even more bone mass, the BHR results seem to show femurs getting stronger.
I suspect, though, that the majority of THR patients are told to avoid impact exercise so this loss would occur anyway.


I am much older than you at 66 and have less to worry about regarding joint longevity, I also have a friend who had his BHR fitted 20 years ago and several who are perfectly happy with their THRs and still go cycling and climbing etc.


I would still encourage you to go for resurfacing as the more elegant solution, whether MoM or metal/poly, but it might well be there is little difference in the result nowadays.


Pete

[catfriend]

Besides the bone preservation issue, the other big advantage to resurfacing that springs to mind is the fact that successful resurfacings can last for 20 years or more. Nobody really knows the endpoint yet, whereas THRs wear out. The more active you are, the faster they go. Obviously this isn't everybody. Some people have problems with their resurfacings and need revision after a shorter period. Also, the devices are still on the newish side. So... nobody knows how long successful ones will ultimately last. If yours last 20+ years before needing a revision this will be better than the active THR recipient who needs a new one after 10 years. At your age you could need 4-5 thr revisions at that rate, although chances are after a revision or two you would be forced to be a lot less active. A successful resurfacing will reduce - if not eliminate - the number of revisions you will need down the road. So... that would be a reason for me.

I would only have a THR if I were not a resurfacing candidate.

[karlos.bell]

  Hi Jsblock11. Cant turn a THR into a BHR but you can do it the other way? Cheers K

[packman]

I'll echo at your age to go resurface - save your femoral head resurface instead
One comparison I have observed is that the immedate recovery to get back up and going quickly is that THR is a much shorter recovery. I saw a golf colleague after 3 weeks up fully walking and driving (albeit not golfing)
He is a big man too and the THR devices are huge contraptions compared to a resurface implant and are intimidating I.e. That's going into me?
Have you visualized the devices?
Resurface IMO is much more muscle invasive but at 38 you have the power of youth to form more bone to graft and adhere to the BHR implants
I know you have a dr that will do both but my searches found tons of Drs who would do THR, few had the expertise and desire to do a BHR due more to training
Pat and the many people on this site were invaluable to me in my first research and finding Dr Gross
If you are still unsure it's within your rights to get a 2nd dr opinion without insulting Dr Ball

[imgetinold]

I think most surgeons who recommend THR do so because either a) they don't do them, or b) don't know much about them.  I had a surgeon say that a THR was a fine option, but that's because he didn't do them.


I agree with everyone else.  Save your femoral head.  I'm 7 years out and going strong.  No issues, and no restrictions.  That being said, BHR surgery is harder on the muscles, and I have never been able to return to running.  I get an ache deep down in my hip....probably some muscle that never quite recovered.  But, I can do an hour long "Insanity" DVD just fine.  Go figure.


But, I play tennis and other racket sports, mountain bike, etc. without issue.  I'm happy to not run if that means an easy, trouble-free revision in 20+ years.


Good luck with your decision, but don't let someone who doesn't do a resurfacing talk you out of it.

By the way, Dr. Gross did my right hip.  He's the BEST there is.

[Joe_CA]

You've already received some great answers already from all the posters on this thread. Did Dr. Ball give you any additional answers why he's possibly recommending THR? What stood out for me was your activity level does not appear to be high-impact, and probably be conducive to THR, though I'm not sure about yoga, and some hardcore mountain bikers (it that's the type of biking you do) would probably chime in and vote for resurfacing.

The only reason I looked into hip resurfacing was I knew that my activities wouldn't be allowed with a total hip due to fear of dislocation. I still think hip resurfacing appears to be a better choice (because you can always fall back on a THR later, and of course I'm biased :-)), but your activities probably wouldn't be curtailed with a THR.

Let us know what you end up choosing.

[LMS]

If you're a good candidate for a BHR, that's what I would go for because of your age.


In 2010 I was a good candidate for a resurfacing but my surgeon cancelled the surgery less than 4 weeks before the big day because he found the joint looked great on x-ray (I though was still in terrible pain).  Fast forward to 2016 & I was bone on bone with a not so great bone quality.  No longer a candidate for resurfacing & great candidate for THR at 47.  I was told that I would be getting a revision in approx 20 yrs or so with the THR compared to much sooner with the resurfacing.


You're young, in your shoes, I would go the resurfacing route. 

[tommyhip]

MY TWO CENTS - There are many reasons to choose HRA over THA - especially at age 38. 1. As stated above, The HRA loads the femur more naturally. In the THA once you jam a stem into the femoral canal you bypass most of the natural top loading stresses and the bone above the stem can degrade.  2. Metal ions are a potential problem with any MOM implant, hip or knee, but remember that many of these ions are naturally removed from the body by the kidneys. AND the metal ion issue seems to be directly related to malpositioning of the acetabular cup. - Too steep (over 50 degrees) may lead to edge loading and excessive wear. On the other hand, HXLPE particles  NEVER leave the body. Ceramic seems to be a better choice for THA. 3. Recovery with HRA seems to be a bit longer as there is more soft tissue handling. Think about it,  When you cut off the femoral head and neck as in THA the acetabulum is right in front of you and therefor easier to access. But the total hip prosthesis is not made to take unusually high post-op forces. Remember Bo Jackson. 4. If you do elect a THA over HRA my view is NEVER employ a surgeon who does not use intraoperative navigation (computer or otherwise) as they will likely not address inclination, offset, and leg length precisely. I had FIVE Os's tell me that they just "eye ball" the positioning. AND Check out the Harvard study that concluded that THA surgeons hit the sweet spot positioning targets only about 50% of the time. The other 50% can expect higher wear and possibly earlier implant failure.  For example, take two identical cars with new tires. Align the front end of one and not the other. Both cars run fine in the beginning but the properly aligned car gets 50,000 miles out of the tires whereas the tires on the  un-aligned car wear out in 20,000 miles. FINALLY, no implant, THA or HRA is made to last forever. At 38, any doctor who does not tell you that a future revision is likely is not giving you full disclosure. A THA can be easily performed on a patient who's HRA has failed - a failed THA will likely need to be revised. PLEASE look at a REVISION on the web - that operation is horrific although sometimes necessary. For that reason alone and being 38 years old I would go HRA. That's what I did. Plus your are buying time for technology and new techniques to come to market.  Good Luck and Best Wishes.