Three years ago, at the age of 50, John Michalek of
Lakeview, N.Y., was frustrated and in pain. Both his hips
were giving out, victims of early onset arthritis, likely
due to an inherited bone structure that produced bad
biomechanics. He considered a total hip replacement. But his
surgeon urged him to wait. The implants last only 10 to 20
years, which meant Michalek would be looking at another
replacement in his sixties or seventies.
He tried swimming and taking anti-inflammatory drugs, but he
didn't want stronger pain medications, concerned that they
might impair his abilities as a justice on New York's State
Supreme Court. It got to the point, though, where the pain
interrupted his sleep. Chasing after his young children and
coaching basketball became impossible.
Some Web surfing turned up a potential solution:
hip resurfacing, a decades-old procedure that is coming back
into vogue, driven by advances in technique and metallurgy,
plus rising demand from an aging population. With
conventional total hip replacement, surgeons slice off the
top of the thighbone and stuff a long stem into the
remaining femur to anchor a new plastic top. But with
resurfacing, a less traumatic procedure, surgeons
essentially sand down the scuffed-up and worn
ball-and-socket -- without removing any bone -- and re-cover
both with smooth metal caps.
The main advantage to the modified procedure: If
the caps wear out -- no one knows for certain how long they
will last -- patients can still get the heavy-duty surgery.
In contrast, a second total hip replacement is difficult
because there is less of the original bone to work with.
Surgeons say that the best candidates for
resurfacing will be younger -- most likely under 60 --
because they are more likely to have the strong bones
essential for the procedure. Also, resurfacing may restore a
more normal range of motion than conventional hip
replacement, making it easier to return to an active
lifestyle. Together, these factors could help push down the
age for those electing to have hip surgery, drawing in
younger patients like Michalek who had been toughing it out.
The average age for total hip replacement in 2002,
the most recent year for which there is data, was 66,
according to the American Academy of Orthopaedic Surgeons.
That year, there were about 345,000 total and partial hip
replacement surgeries, including revisions.
Why would someone younger need a hip replacement?
The reasons include early onset arthritis due to conditions
like hip dysplasia (where people are born with an unformed
or malformed hip joint), rheumatoid arthritis and trauma,
which can lead to avascular necrosis, in which the top of
the femur is starved of blood and dies off.
Resurfacing is not without risks: It involves
essentially the same incision as replacement surgery does --
sometimes a longer one -- to give surgeons a full view of
both the top of the femur and the hip socket, said Michael
Mont, a joint specialist at Sinai Hospital in Baltimore. He
has been conducting hip resurfacing trials for Wright
Medical Technology, an Arlington, Tenn.-based company
seeking Food and Drug Administration (FDA) approval for its
device. And resurfacing may require more time in the
operating room -- Mont said it takes two hours, compared
with one hour for conventional hip replacement -- and a
slightly longer rehabilitation period.
There's also some evidence that the two metal
surfaces -- both made of high-carbon cobalt chrome --
degrade and disperse metal ions into the bloodstream. But so
far there's no indication they will break down quickly or
that those ions cause health problems like cancer.
Double or Nothing
To date, hip resurfacing has mostly been done
overseas. But in the last five years, several companies have
been testing their resurfacing devices at several medical
centers around the United States. Before his surgery,
Michalek traveled to Baltimore to meet with Mont.
Even though there was not much long-term research
on hip resurfacing and his insurance initially refused to
cover the experimental procedure, Michalek decided to go
ahead and repair his faulty left hip joint. (Hip replacement
is covered by Medicare and private insurance; Michalek's
insurer ultimately agreed to pay for his hip resurfacing.)
The improvement was immediate. After 10 weeks on
crutches and a cane, he went back to the treadmill and
StairMaster, and he returned to coaching. When the pain in
the right hip got to be too much, he had the right side
repaired, in late September.
Suzanne Vega of York, Pa., came to a similar
decision at an even younger age. The 37-year-old has
rheumatoid arthritis, a disease where the body attacks the
joints. In her case, the inflammation and deterioration
occurred mainly in her hips.
After the birth of her fourth child in 2001, the
pain got so bad that Vega could no longer work as a
registered nurse. Her rheumatologist recommended a total
replacement of both hips. But she wasn't wild about getting
the implants, knowing they would likely need replacing --
maybe even twice during her lifetime.
Vega's research and networking led her to Mont and
hip resurfacing.
On Sept. 1, Vega had her right side resurfaced. A
little more than a month later, she had the left side done.
"I think it's a really good option for someone my
age," said Vega, noting that it will let her keep most of
her thighbone intact. And, she says, most of her deep bone
pain has disappeared.
Hip Chats
How many Americans would be eligible for, or choose
to get, resurfacing is unclear -- but interest is evident.
Craig Thomas, an orthopedic surgeon who studied under Mont
and practices with the Rankin Orthopedic Group in the
District, says he has about 50 patients waiting for the FDA
to approve a device so they can have the procedure. A Yahoo
discussion group (
http://health.groups.yahoo.com/group/surfacehippy/ ) for
people considering the procedure and others who have already
had resurfacing has averaged 1,500 to 3,000 messages a month
this year.
Those who have had the surgery as part of a
clinical study tell of having to fight for insurance
coverage of the procedure, which may cost $30,000 or more.
In early September, an outside advisory panel to
the FDA narrowly voted to support approval of the first hip
resurfacing device to come up for review, the Birmingham
Hip. The Smith & Nephew device is sold in 23 countries and
has been implanted in 33,000 patients. The British company,
which has U.S. operations in Memphis, submitted safety and
efficacy data on about 2,000 patients, but they were not
part of a rigorous clinical trial. The lack of a
gold-standard data set led two of the five advisers to vote
against approval.
Whether or not the FDA approves the Birmingham Hip,
a resurfacing device is likely to eventually pass muster and
get to market, possibly within the next year, according to
the manufacturers and Wall Street analysts.
Cecil Rorabeck, a professor of surgery at the
London Health Sciences Center in London, Ontario, and a
consultant to Smith & Nephew, says he generally does
resurfacing only in patients under 60, and not in
post-menopausal women who have significant osteoporosis.
That's because, with the Birmingham Hip or other resurfacing
devices, a small peg is inserted about six centimeters into
the top of the thighbone. That increases the risk for a
fracture, especially in the first six months. Of the Smith &
Nephew patients, fewer than 1 percent had a fracture, he
said.
The fracture risk is much less with a total hip
replacement, because the top of the thighbone is cut off.
The stem for the new top is inserted 14 centimeters into the
remaining bone.
Resurfacing has many hypothetical advantages. The
covering for the ball can be pretty closely size-matched to
the patient's natural ball. That significantly cuts the risk
of dislocation (a common problem with total hip
replacement), and appears to give patients a much more
normal range of motion. A small study by Mont showed that
resurfacing patients walked almost normally, while those
getting a total hip replacement still had some deficits.
Betting on the Future
Since resurfacing patients tend to be younger and
feel more normal, they are more likely to go back to their
lives and be more active. But surgeons say they caution
against doing too much.
"I don't encourage people to go out and play
basketball, but I can assure you that people are doing it in
spite of that," said Rorabeck.
Tony Rankin, Thomas's partner and chief of
orthopedics at Providence Hospital in the District, says
that younger patients always try to do more -- even those
who've gotten a traditional total hip replacement. He
advises against skiing and other load-bearing activities
that can stress the new joint, and says he'd give the same
advice with resurfacing.
When asked whether the resurfacing implants will
let patients do more, Rankin said: "My gut feeling is no."
The biggest question about the implants is how long
they will hold up.
"I'd like to think these will last 20 or 30 years,
but I can't say that," said Mont. And Thomas said, "We
advise patients that you're most likely going to need
another surgery; we just don't know when."
Patients who have gotten the implants aren't too
concerned, though.
"If this gives me five or 10 years of more
normalcy, I'll take that," said Michalek. "Even if it
doesn't last, I could still go tomorrow and get it
replaced."
Alicia Ault last wrote for Health about computer
games designed to speed healing. To comment on this story,
send e-mail to health@washpost.com.
