Dr. Brooks of the Cleveland Clinic

4/2/2013

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

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Dr. Rogerson of WI

4/3/2013

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

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Dr. Gross of SC

4/3/2013

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

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Dr. Amstutz of CA

4/1/2013

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

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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:

Read Original News Release by Clicking Here

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.

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Dr. Julien Girard of France

2/14/2012

Study – Return to running possible after hip
resurfacing

Recreational runners who undergo hip resurfacing…
may be able to return to the sport after surgery, according to a
recent study from France.

Researchers found that more than 90 percent of hip resurfacing
patients who ran before surgery resumed running afterwards.

“I’m convinced that quality of life is strongly correlated with
sports possibility for younger patients,” said lead author Dr.
Julien Girard, an orthopedic surgeon at Lille University Hospital in
France in an email to Reuters Health…

…For the new study, researchers followed 36 male
and 4 female patients, average age 51, who were runners before hip
surgery. A total of 43 hip resurfacings were performed on the 40
patients.

At the end of about three years, 33 of 40 patients (36 of 43 hips)
were still running.

The runners spent a similar amount of time – about three hours per
week -running after the surgery as they had before. Their weekly
mileage decreased significantly, however, from about 24 miles a week
to 16 miles a week among the patients over age 50…

…While the results suggest that a return to running is possible
after hip resurfacing, the study did not look at the long-term
effects of wear on the implant.

Other studies have found that patients can maintain a high level of
activity for 10 to 20 years after surgery.

Running doesn’t appear to harm the longevity of the implant, but a
follow-up of more than 20 years is necessary to draw firm
conclusions, Girard said.

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Dr. Su of NY

I am often asked by patients what sorts of
activities they may expect to do after a hip resurfacing. To this, I
am happy to respond, “EVERYTHING!” Of course, each patient and each
hip situation is different, but the entire purpose of going through
with the operation is to get back to doing the activities that you
love doing. Once the healing process has occurred and the bone
around the implants has strengthened, I release you from all
restrictions.

I have many patients who are martial artists, dancers, yoga
practioners, swimmers, cyclists and weight lifters. Many patients
play competitive tennis, soccer, squash, racquetball, basketball,
and volleyball. My most active patients are triathletes and
marathoners…