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1. The Birmingham Hip resurfacing
is what I prefer.
It has given me good results and has the greatest worldwide
experience. It was the first SR approved by the FDA for
utilization in the United States. I was one of the first
surgeons trained on it and I trained with master surgeons in
England who designed this prosthesis. I continue to have
excellent results. It does not have some of the problems of
loosening of the femoral head components that are reported
with some of the other designs that “allow for a cement
mantle”. Since I am having good results with it, I find it
difficult to consider changing.
2. I prefer the posterior
approach.
It is the approach which I have utilized the most for hip
surgery during my18 years of practice and the one which I
have taught to the most student physicians. It was also the
approach utilized by the surgeons who developed the
Birmingham Hip Resurfacing and it has worked well in their
patients with 10 year follow-up, therefore, I will continue
to utilize this approach.
3. The bone fully heals into the
socket (acetabular component) within six to eight weeks.
The femoral component or the resurfacing component of the
femoral head is cemented into position. Therefore, there is
no healing really to occur into the prosthesis. However,
because of the risk of femoral neck fractures, virtually all
of which occur within the first six months, I recommend that
patients not perform running or impact sports for six
months. I am more interested in their long-term functional
success and in the intervening time I think they can
exercise with exercise bicycles and similar low impact
work-out techniques.
4. Cementless Devices.
I feel the cementless devices for the femoral component will
suffer a rather high incidence of failure within the first
five years due to femoral component loosening. The patients
will likely develop avascular necrosis or bone death of the
femoral heads in a certain percentage of patients, even
those who have anterior approaches. The bone will therefore
not grow into or attach itself to the resurfacing component
and the components will loosen and cause a painful failure.
Since the cemented Birmingham hip resurfacing technique is
working well, I do not see the need to risk the cementless
approach for the femoral component at the present time.
However, the cementless is the way to go for the acetabular
components as there is no problem with avascular necrosis or
bone death of the hip sockets after surgery. I would not
cement the socket and I do not know anyone who would.
5. The length of the incision
per se really does not influence the rehabilitation.
What we have clearly learned from the minimal incision
literature and experience with all total hips is that with
less tissue disruption one can perhaps rehabilitate a few
weeks earlier, however, since the surgeon is seeing less,
despite many claims to the contrary, there will be a higher
incidence of sub-optimally positioned components, creating
higher wear rates and more metallic debris generation. With
currently available techniques, it may not make sense to
sacrifice years of function just to get the patient back on
their feet in an ideal manner two to four weeks earlier than
they would recover anyway. That being said, most of us have
begun to make more conservative length incisions compared to
those that we made a mere 5-10 years ago. Most hip surgeons
have learned to do just as well with these smaller
incisions. However, one must be aware that the incision
needs to be long enough for the surgeon to do the job right
and to get good longevity of the reconstruction.
6. Do You Preserve the Hip
Capsule?
On some cases I preserve the hip capsule and repair it at
the end if it is present, but the resurfacings tend to be so
stable that it is not a major issue and it can be
sacrificed.
7. What is the advantage of hip
resurfacing compared to a total hip replacement?
I consider hip resurfacing a type of hip replacement. It has
the advantage of bone preservation. I think this is ideal
for the younger patient and the active patient. Once healed,
it possesses a greater stability with less chance of
dislocation than conventional hip replacements. This is also
true for some of the modern total hips that utilize large
metal on metal articulations. They also have enhanced
stability. However, the main advantage of a resurfacing is
preservation of the proximal femur and potentially a more
normal hip in that one is still articulating with a femoral
head of approximately the same size as the original femoral
head. Surface replacement is not appropriate in an elderly
patient because the femoral neck tends to be osteoporetic
and weak and the risk of a femoral neck fracture is too high
to warrant it use. Furthermore, although it is bone
preserving, it does require more dissection of the soft
tissues to adequately displace the femoral head out of the
way of the socket so that the surgeon can perform his
acetabular work, including socket replacement. Despite
multiple claims to the contrary, one can do a total hip with
a little less tissue disruption because you simply cut the
femoral head out of the way to gain access to the hip socket
to work on it. Thus, surface replacement is, at a minimum, a
little bit more tissue disruptive than a total hip. The more
tissue disruption, the more difficult the rehabilitation.
This is the second reason why elderly patients are not
candidates. In addition to their osteoporosis and femoral
neck weakness, they have less physiologic capacity and less
ability to recover from the surgery and their rehabilitation
will be even more difficult. As a rule, resurfacing patients
rehabilitate very quickly and the majority of my patients
are discharged on the second postoperative day. This is
largely due to their younger age and greater vigor, not the
difference in surgical technique per se. This compares to
most of my total hip patients who primarily go home in three
to four days. However, my total hip patients tend to be an
older population and although their surgery required more
bone sacrifice, it required less soft tissue dissection.
However, because of their overall health and age, they tend
to stay in the hospital longer, not because of the surgery
difference per se, but simply because of their age.
The strongest endorsement I can give for hip resurfacing, as
opposed to a total hip, is that if I or a member of my
family of my approximate age (54) or younger (or even 5-10
years older and active) required some sort of hip
replacement, I would choose a hip resurfacing. I personally
would choose a Birmingham Hip Resurfacing.
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