Dr. De Smet Interview by Patricia Walter Sept. 5, 2009 in
Baltimore, MD at the 3rd Annual Hip Resurfacing Course.
Dr. De Smet Interview by Patricia Walter 2009 from Surface Hippy Videos on Vimeo.
Dr. De Smet of Belgium interviewed by Patricia Walter in Baltimore, MD 2009. Dr. De Smet discusses hip resurfacing, the Birmingham Hip Resurfacing Device, patient selection, surgical approaches and patient outcomes after hip resurfacing.
Does the length of incision influence the rehabilitation?
No! A bigger incision does not mean that there will be more
damage to the muscular structures. On the contrary, if you
need a bigger incision to get better exposure, the placement
of the implant can be done more precisely. Even with an
incision of 30 cm you are able to walk well after 24 hours.
In the resurfacing procedure the incision is longer than THR
(15 – 30 cm/6-12 inch) because of technical-anatomical
reasons (saving the femoral head). The length of incision
has no influence in the postoperative rehabilitation.
Which approach do you use?
For the resurfacing procedure I always use the
posterolateral approach for technical reasons. For a classic
total hip replacement I changed after having performed 1800
procedures from lateral to posterolateral approach as well.
The posterolateral approach does have many advantages:
abductors (gluteus medius muscle) responsible for normal
gait remains intact, so less patients suffer from permanent
abnormal gait after hip prosthesis.
2. There is a much better
view to place the components in a more correctly way (very
important for revision surgery).
3. There will be less
repetitive muscle damage in revision surgery; there are
fewer patients with complaints of trochanteritis (irritation
of the bursa) compared to the lateral approach.
disadvantage of the posterolateral approach is the larger
incidence of dislocations in inexperienced hands / learning
What is your
opinion about cementless devices for resurfacing?
Maybe they are good, but we do not know yet. Cement is a
shock absorber between prosthesis and bone or between
prosthesis/ bone+cement/ bone, so maybe a good thing,
certainly taking in account that Chrome Cobalt has not the
same elasticity as bone and is quite stiff!
Do you preserve
the hip capsule during your hip resurfacing surgeries?
Yes, and I think you should.
Why is Hip
Resurfacing better than Total Hip Replacement?
Theoretic advantages are less bone destruction,
less bone resection, normal femoral loading, avoidance of stress
shielding, maximum proprioceptive
feedback, and restoration of normal anatomy. In addition,
reduced risk of dislocation, less leg inequality problems, and
easier revision should convince surgeons to favor metal-on-metal
Why does my hip
Also called peeping
or "peepcreep". The squeaking noises
are produced due to a temporary lack of
lubrication, a dry running of the metal-on-metal
prosthesis. It sounds as a non-lubricated
creaking hinge of a door. The duration of the
noise is normally less then 24 hours, and a
It starts when the patient has an increase or
change in activities. Stair climbing always
generates or increases the noise. (Possible
provoking activities: mountain climbing,
mountain walking, chopping wood, etc).
It does not occur any more 2 years after
surgery. Two year is the time interval that
equals the running in period of a metal-on-metal
friction couple. Running in means that the
prosthesis is polishing itself. Immediately
after surgery, the lubricant (lubrication film)
between the 2 components of the prosthesis is
blood. This will change to serum with our own
proteins after a while. The percentage of
patients where squeaking noises appear is about
It is a benign incident that goes away
spontaneously and you do not need to panic. (let it
know to your surgeon for statistical reasons!).
What Should I do
We prefer ice packs, although both are
effective to relieve pain. Both can be harmful in direct
contact with the skin. It can damage the skin and even cause
a severe burn. Never sleep with a heating pad on your hip.
Ice can be used several times a day. Twenty minutes on, 20
minutes off, is the usual regime. In the first postoperative
weeks heat is not recommended.
How old is the
BHR procedure is developed in 1996/97.
The first metal-on-metal resurfacing is from Feb. 1991. The
resurfacing is already 40 years old, metal-on-metal is 40
years old (the oldest dates from 1938!). Both ideas were put
together by Mr. McMinn in 1989.
How old is the
oldest Wright C+ hip?
The Conserve Plus design was introduced
by Dr. Amstutz in 1995.
Oldest C+ hip dates from the year 1996.
Can both hips be
operated at the same time?
In severe osteoarthritis of both (bilateral) hips a
bilateral procedure can be done. Both hips are operated on
the same day. Our experience today has not given more
problems when this is performed in healthy people. A
continuous epidural catheter and more blood transfusion are
needed. Cell saver is used in these conditions. Patient has
to be healthy, not obese, and the hip condition itself does
not have to be severe.
What kind of
physical therapy do you recommend for your resurfacing
Everything like they feel. For general rehab you could take
6 weeks, 3 months. If patients want to progress harder they
can have longer or more frequent physiotherapy, but this
would then be more like fitness training ! Physiotherapy in
resurfacing is more guiding the patients then making them to
work out exercises too fast and too hard. Passive forced
flexion of the hip should not be done. It will often lead to
What is the
normal recovery time?
1 to 2 weeks 2 crutches, 1 to 2 weeks 1 crutch. No cane.
What is normal exercise? Actual daily living means 4 to 5
weeks. More strenuous activities can begin from then one,
like patient feels for himself. Patient has to be his own
Will I have
Stitches or Staples?
Normally staples are closing the wound.
In young patients (ladies!) and on request the wound is
getting closed intracutaneously.
Half of the stitches or staples are normally removed after
14 days. The remaining half is removed after 16 days.
Depending on the individual patient, one can decide to
remove the staples later on. Staples are removed with a
In case of an intracutaneous suture, one only has to cut off
one end of the suture. It is not the purpose to remove the
complete suture because it is resorbable.
How long will my
leg continue to swell and hurt?
The pain usually decreases rapidly during the first days,
but discomfort can continue for a couple of months. The
swelling is due to alterations in fluid return up the limb,
and will gradually diminish, but may take a couple of months
or longer. Mobilization, exercise, stockings and elevation
What is the
worst complication that you are aware of with resurfacing?
Fracture of the neck of femur. When it occurs, you get a
stem with a big modular head. I have only one patient with
this, but afterwards he is now, one of my happiest patients.
In most of the series, all over the world, fractured neck of
femur has an incidence of 1%.
complications might I be at risk for?
None more then with any other procedure: infection, nerve
lesion, thrombosis, death?
The chance of unequal leg length or dislocation is much
lower than in THA.