Dr. Su video interview by Vicky Marlow Freelance
Patient Advocate Volunteer May 2008
Dr. Su Video Interview about Hip Resurfacing
1. How did you
get started with Hip Resurfacing and tell us about your
background and experience as a surgeon. Where did you
train for hip resurfacing? Who trained you? Did
you continue your training after starting resurfacing?
I did my residency training for
orthopaedic surgery at the Hospital for Special Surgery and
stayed afterwards to do a fellowship in joint reconstruction
and replacement.
During residency, I had the opportunity
to attend a visiting lecture by Dr. Harlan Amstutz on his
experience with hip resurfacing, both past and present. I
was struck by his commitment to the idea of bone
preservation, and the challenge of implant longevity in
younger, active patients. This led me to seek additional
training in this technique, so I spent about 3 months with
Dr. Amstutz to learn from him. I was so excited with the
technique that I brought it back to HSS and performed the
first modern generation hip resurfacing at our hospital in
2004. I realized that hip resurfacing is a more technically
difficult procedure than hip replacement, so I sought
additional training from experienced surgeons around the
world. I visited Dr. Koen DeSmet, Dr. Thomas Gross, and Mr.
Derek McMinn in order to learn from the masters.
2. You
started doing neck capsule preservation in your surgeries,
can you tell us a little about the reason for doing this and
explain to us more in detail exactly what it is?
Neck capsule preservation is a technique
described by Dr. Vijay Bose, one of world’s foremost hip
resurfacing experts. It is a way of performing the hip
capsule release to preserve the soft tissue around the neck.
This may help preserve some of the blood supply to the
femoral head. It is also a method in which the capsule can
be repaired after the resurfacing so that the hip is more
stable.
I became interested in the technique when
I heard Vijay speak about it at a resurfacing meeting. It
made a lot of sense to me, and could perhaps explain the
excellent results that he achieved.
3.
What is the normal hospital stay barring any complications?
Usually patients stay 2 days (that is, if
surgery is Monday, they leave on Wednesday), but some
patients have left the day after surgery, and others have
stayed 3 days. However, it is something assessed on a daily
basis and depends on whether or not it is safe for a patient
to be discharged. We look for the ability to get in and out
of bed independently, use crutches, and go up and down
stairs.
4. What is your
typical recovery time after resurfacing? What is your
typical rehab protocol? 90 degree restriction?
Walker, Crutches or Cane? Length of time used?
Blood thinners? TED stockings? Ice? PT?
The typical rehab protocol is weight
bearing as tolerated on the operated leg, using a walker the
first few times the patient gets up. Then, we will advance
you to using two crutches, either the axillary (armpit) or
lofstrand (forearm) crutches, depending on your preference.
They are used like walking sticks, so you are still putting
full weight on the leg and walking with alternating steps. I
like you to use the crutches for walking for about 2 to 3
weeks. They are to provide additional stability so that you
don't fall and for my peace of mind. Many patients are able
to walk 1 mile at a time, at 2 weeks after surgery. At this
point, the best thing for your recovery is simply walking,
and you will be able to do exercises on your own. We
will send a therapist to the house 2-3 times per week to
help guide you, but before long, you will be independent.
You can also ride a stationary bicycle, swim, and exercise
your upper body in the gym during this time. I don't
impose any 90 degree restrictions postoperatively. In fact,
I find it important to begin mobilizing your hip.
After 2-3 weeks of using 2 crutches,
you'll advance to 1 crutch or a cane. Shortly thereafter,
within another week or so, you'll be walking without
anything to help you. At this point, you will be ready to go
to outpatient therapy. The main purpose of outpatient
therapy is to mobilize the hip and strengthen the muscles
around the hip. In addition, after the first postoperative
visit, I will show you some stretches to help you regain the
motion. This phase of therapy will last about 1-2 months.
You may begin to play tennis, golf, and
cycle outdoors at about 6-8 weeks postoperative. I
like you to remember that the hip is still healing at this
point, and heavy lifting over 50 lbs and impact activities
should be avoided until you are 6 months postop.
After 6 months postoperative, I remove
all activity restrictions -- it's your hip!
In general, I use a full strength, coated
aspirin (325 mg) twice a day for 1 month following surgery
as your blood thinner. Certain patients will require
stronger blood thinners. TEDS stockings can be very
helpful if you experience swelling, and would be used while
a patient is up and around during the day (since fluid tends
to accumulate by gravity).
5. How long
before a typical patient is allowed to drive a car, return
to work?
For driving, usually a left
hip patient can drive after about 2 weeks, as long as they
are off pain medication. If it was a right hip surgery, you
may need an additional 1 to 2 weeks to make sure you can
lift the leg from side to side. A manual transmission
will take 3-4 weeks postop for either side.
6. What is the
recommended time you tell your patients before they can
start to run again/do impact sports? Are there any
sports you don’t want your patients to participate in after
surgery? What are some of the sports your hip
resurfacing patients have returned to?
As stated above, I remove activity
restrictions at 6 months. I would ideally like the hip
resurfacing implant to last as long as possible, and I feel
that repetitive running on hard surfaces may be detrimental
to the implant and it's connection with the bone. If a
patient feels strongly about running, I would prefer it be
done on a softer surface.
Patients have returned to such activities
as: marathons, rugby, volleyball, mountain climbing, hiking,
ballroom dancing, performance dance, Thai kickboxing, mixed
martial arts, judo, tae kwon doe, soccer, baseball,
pitching, basketball, golf, tennis, among others.
7. What is your
opinion about cementless (femoral) devices for resurfacing?
I think it is an intriguing idea, a
natural extension of what we have learned from total hip
replacement. However, there is very little known about it at
this time, and although I have done it in a few cases, I
would like some additional follow-up information before
doing it on a widespread basis. The theoretical
advantage is that once the bone grows into the femoral cap,
it should be integrated into one's own body and have very
little chance of loosening. This might perhaps be better for
impact sports. However, the downside is that there may
be gaps between the bone and the implant initially because
of bone wear or cysts, or there could be a failure of
ingrowth. Thus, the failure rate of cementless resurfacings
could potentially be higher than cemented resurfacings, if
applied to all patients.
8. Do you
have a cut off age for resurfacing patients or do you go on
a case by case basis?
I go on a case by case basis, since there
is so much variation between a patient's physiologic and
chronologic age.
9. What
type of anesthesia do you use, general or epidural ?
At the Hospital for Special Surgery, we
use epidural anesthesia, which will then be connected to a
pump so that a patient can control their own medication, on
demand.
10. Are
there any cases that you will not take in particular, AVN,
dysplasia, small cysts. Maybe touch on some of the
very difficult cases you have been able to resurface.
There aren't any particular categories of
cases that I would not be willing to resurface. However,
resurfacing does depend a lot upon the strength and
structure of the bone. So there are some cases of large
cysts (holes) that have formed in the femoral head, or
avascular necrosis that has caused a large portion of the
bone to die. In these cases, if more than 50% of the femoral
head is deficient, a resurfacing may not have much to
support it.
I have been able to do some challenging
cases of patients with prior surgery from fractures, slipped
capital femoral epiphyses, hip dysplasia, femoroacetabular
impingement, Legg-Calve-Perthes, and AVN.
11. Do you
do bilateral surgeries the same day, if not how far apart do
you recommend?
Yes, I have done over 40 bilateral hip
resurfacings on the same day. In certain instances, a period
of time may be recommended between surgeries, depending on
the medical health of the patient. If a patient is not
healthy enough to have the surgery done on the same day, or
it would require too much operative time, a patient can
still have it performed during the same hospitalization,
with 3-4 days between the sides.
12.
If you can’t perform a hip resurfacing, what THR device do
you prefer and why?
If I can't perform a planned resurfacing
operation, I would typically use an uncemented THR with a
large diameter metal head. If we have another reason
for not wanting to do a metal-on-metal bearing, then I
generally use a ceramic-on-ceramic THR for my younger,
active patients.
13. What
do you consider an adequate number of surgeries for a doctor
to be proficient at hip resurfacing?
This is a tough question to answer,
because obviously every surgeon has to begin somewhere. Hip
resurfacing is definitely a more challenging operation to
perform than total hip replacement. That being said, a good
hip surgeon who is experienced with THR should be able to
make the transition fairly easily.
However, each patient's anatomy is
different, and to really appreciate the subtleties of
implant placement to produce not only the best short-term,
but also long-term results, I think 100 hip resurfacings
would be a reasonable number. Also to be taken into account
is the frequency of performing them; hip resurfacings should
be performed consistently, otherwise the learning curve will
not advance. Thus, a frequency of at least 5 to 10 per month
is probably the minimum number.
