I was not keen to do the ASR when it was introduced. After a couple of years when surgeon friends told me that it was good and I saw the results, I tried it out in a phased manner.

Currently I use the BHR and ASR to almost about 50% each.

I make the decision based on technical preference in the particular patient. I think the BHR and ASR are best suited for opposite ends of the spectrum of patient and bone size.

One important advantage of the ASR is the small stem (peg) it has for the smaller sizes. This is the huge advantage in small built individuals as the proportion of the stem ( peg)to the residual bone is less. In contrast the BHR has a same size peg through all sizes. A large peg in a small head size has the potential problem of causing stress shielding . I almost never use the very small size BHR like the 38 anymore.

In very big built patients who are bound to return to sports etc very soon the BHR is the preferred option as the cup has a more high profile surface for bone contact with a plastic disc for heavy impaction. The ASR is more fine and seats without much impaction. This may be an advantage in relatively soft bone.

The other important way to harvest the advantage of prosthesis design is the selecting the prosthesis based on the amount of head bone involved. The ASR certainly removes less bone in the head than the BHR. This could be used to the advantage of the patient in a condition like ankylosing spondylitis where the problem is only in the articular cartilage with the bone being intact. Here the ASR scores over the BHR.

However in a pathology like AVN there is significant head involvement, the BHR has a distinct superiority as one would like to remove the diseased bone and replace it with the metal.

Osteoarthritis lies somewhere inbetween where some patients have significant head involvement where the BHR would be superior and in some others the head bone may be largely intact and the ASR would be a better option.

Thus I choose the prosthesis based on technical issues and employ it to the patient’s advantage. Thus in my practice both the ASR and BHR complement each other. After doing more than 200 ASR over the last 2-3 yrs , I am as impressed with the ASR as with the BHR.

I was one of the first to try out computer aided surgery for resurfacing. This has no advantage except in patient who have had previous surgery like a osteotomy . It has a very important disadvantage of removing all the capsule and soft tissues on the neck of the femur ( to take a computer reading known as bone morphing). This will compromise blood supply. I have to say that currently for resurfacing computer aided navigation is only a marketing tool for surgeons/ companies. Computer aided navigation is very beneficial in knee replacements where one has to align the knee components to the hip and ankle and I use it routinely for knee replacements.

Wishing you the very best

With best regards

Vijay bose
chennai
Asian Regional Center for Hip Resurfacing (ARCH) Website
 

Dr. Paspati

I offer both prosthesis, the BHR and ASR  to my patients, as I am trained to do both.

The changes on the ASR are such that they have taken the good points of the BHR (so in the long term the result should be the same as the BHR), and eliminated some weaknesses of the BHR (so that in the long term the results might be better!). So all in all, it appears that the ASR should do better. When the BHR started, people did have concerns about it at that time, and that would happen to anything new. The ASR is not brand new! It has been around in clinical practice for 1.5 years now, and as part of research trial prior to that.

If you look at it a little differently - would you choose say an average resurfacing surgeon (but who does the BHR) or a brilliant surgeon (but who does the ASR?), if at all you were in such a scenario?

Taking into account the patient perspective and the doctor perspective, I think its important to select a good resurf surgeon first. If that surgeon offers both prosthesis, you can choose. And if he does not, then stick to the good surgeon and go by whatever prosthesis he uses.

I know there is no fixed correct answer here (and you know that too!!!). These are just perspectives.

Regards
Ameet Pispati
 

 Dr. Rogerson

I definitely prefer the Birmingham prosthesis compared to the others on the market. This relates to the metallurgy with the as cast large block carbides and better wear than the heat treated metals, the precise instrumentation and the line to line fit of the femoral component, and the truly impressive results at 10 year follow-up.

For the US surgeon, I prefer the Cormet device because I believe the Cormet approach does a better job of helping the American surgeon provide the American patient with a durable and predictable long-term successful result. As I have mentioned above, the long-term success of such an operation depends on using a well thought out, well designed and manufactured device, making certain that it is implanted properly, and being certain that is placed in the appropriate patient. We have been very fortunate in the US to have many different technologies and well designed/manufactured devices available for addressing end-stage hip disease. We have technologies that are now showing successes out to 25 years. This has not been true for our colleagues around the world. Corin submitted the Cormet device to the US for clinical trial in 2001, and committed itself and its investigators to learning about the operation and the devices. This is a very important step in the process of new technology introduction, as surgeons and companies find it easy to promote operations and devices, but don’t always provide the necessary steps to insure that the introduction of that technology to a broader population can be done safely. The BHR has enjoyed widespread success worldwide because of the significant educational efforts of Mr. McMinn and his colleagues. They have responsibly introduced the resurfacing operation, and educated surgeons and patients on its performance. I am concerned that that has not been the case in the US, where FDA approval was granted based upon Mr. McMinn’s significant success, but few American surgeons had come into contact with the device and instruments. Corin, however, has performed a clinical trial with the Cormet device, and with its partnership with Stryker, has committed to the most thorough, consistent, and vigorous training and education program in the US. As is Mr. McMinn with the BHR device, I am biased about the product and support behind the Cormet device (I am a consultant surgeon for Stryker and a part of their teaching program) because I believe that it will allow American patients to receive an excellent device, implanted properly in the appropriate patient, and with the best chance for long-term success.