I have been
in practice about 25 years now, specializing in joint
replacement. My partner, Jim Hartford, also is fellowship
trained in replacements and we've been together now for
about 6 years (PAMC is a big multispeciality clinic with 11
orthopaedists). Now but Jim and I do almost all of the
replacements).
We became
interested in hip resurfacing because we saw a demand for
hip replacements in a physiologically young group of
patients who wanted to be very active and yet that was the
group with the highest failure rates in conventional hip
replacement. As metal on metal resurfacing became more
successful, we had a group of patients who would seek it out
and for a few years, I would sometimes send someone to LA to
Dr. Amstutz or Tom Schmalzreid who had studies going on.
Also had
a friend of mine go to Belgium and come back with two hip
resurfacings doing great!
When the BHR
got approved, Jim went to Calgary for training and I went to
England and trained with Mr. McMinn. We've been doing
them now for about 2 years. We did one thing which I think
is almost unique in that Jim and I decided we would try to
do as many of these as we could together. We thought that
would be valuable in two ways. One was to increase both our
experience simultaneously which we thought would help cut
back our learning curve and Two, we thought patients would
benefit from having two experienced hip surgeons working
together. We've really enjoyed that and we think our patients
like the idea, too. We have around 120 now but are getting
more nowadays because of word of mouth and patients seeking
out doctors with experience. It was quite difficult at first,
of course, to attract patients as we were very honest about
learning curves, etc. and many would shy away, but now we are
doing about 12/month and doing pretty well for the most
part.
One of us
acts as the primary surgeon, with the other assisting.
We
run two rooms and go room to room so we each have been the
primary for about the same number of patients and assisted
similarly. We have done a few patients without the other
surgeon which is easier now that we have some numbers but we
still enjoy the team approach and try to have what we call
our BHR day twice/month working together as a team of the
two surgeons (and we have two great PA's, Liza and Rob).
We both use
posterior approach. We use a curved incision, so hard to
measure length, but probably 6-8 inches. Close with a subcuticular suture so we do not get the "railroad tracks"
of staples. We let our patients put weight on as
tolerated from the start but with a walker or crutches and
then wean to a single crutch or walking stick as soon as
they are comfortable. Do follow posterior precautions
with no crossing leg in flexion, limit flexion to 90 degrees unless
they are abducted at the same time in which case they can go
past 90 degrees for 6 weeks. We do not recommend high load such as
running for a full year. We base this on maturation of the ingrowth into the cup and statically higher fracture risk if
overloaded early though some patients "cheat" and seem to do
fine. We have had one femoral neck fracture at 3 weeks
post-op, have had one unstable cup requiring revision and
one arterial injury requiring vascular surgery repair. No
infections, pulmonary embolisms, etc.
We do not age
or sex discriminate but go rather on activity and bone
quality. Most patients are males under 55 and we do have
a tendency to quote Australian registry data. We do believe
hip replacement is a good alternative, especially if bone
quality is questionable. We do use only the BHR.
We do only hybrids - that is cemented femoral components
with cementless cups again based on the more favorable data
of these constructs (though I still would love to see
femoral fixation without cement if a design could be shown
to be as excellent as the cemented). We always preserve and
repair the capsule if possible.
The ideal
candidate in my opinion is an active person with good bone
quality with a long life expectancy who wants to maintain a
high activity level and wants to preserve bone. Also that
they recognize that we do not have all the answers comparing
modern total hip to modern resurfacing and that all implants
of whatever style have potential advantages and
disadvantages.
John Lannin,
M.D.
