Birmingham Hip Resurfacing

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Birmingham Hip Resurfacing

• Just say YES
• (to the right patient)
• Or send them to
• Wake Forest

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Birmingham Hip ResurfacingLessons from my First
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• William G. Ward, M.D.
• Dylan Lippert, MSII
• Riyaz Jinnah, M.D.
• Wake Forest University Health Sciences

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Arthritis

• Rising incidence with aging population
• Over 600,000 total joint replacement operations
  annually in USA
• Over 7 billion annual cost in lost time from
  work
• Many pain, movement and quality of life issues
  associated with this disease

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Total Joint Replacement

• One of most successful operations in modern times
• Radically impacts quality of life
• Restores life to otherwise crippled individuals

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What is a Resurfacing Procedure?

• Recap femoral head
• Bone conserving retains femoral neck and most
  of head less invasive
• Cemented femoral head prosthesis about the same
  size as patients - mated to the patients
  acetabulum resurfacing
• Metal-on-metal surface
• Transmits stress to the femoral neck rather than
  the shaft minimizes stress shielding

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Resurfacing hip replacement
Standard total hip replacement
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Is the procedure new?

• Historically, began in the 1960s and 1970s
• Femoral resurfacing was used with polyethylene
  acetabular cemented component.
• Was abandoned due to loosening of acetabular
  component - particulate matter (wear debris)
• Some didnt last five years

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What was changed

• Metalmetal interface avoids polyethylene wear
  debris (3)
• Large head sizes optimal for metal-metal
  interfaces fluid film lubrication
• Improved manufacturing practices better true
  roundness harder materials

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Which is harder to perform? Standard THR or BHR

• BHR is harder
• Must work on acetabulum without cutting femoral
  head and neck off to allow access
• Must make an anatomic pocket to displace
  femoral head while working on acetabulum
• i.e. must relax and release more soft tissues
• More Bone Conserving
• More Soft Tissue disrupting more invasive
• No bigger than historic standard incisions

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What type of patient is a candidate for
resurfacing?

• Physiologically 60 years of age and younger
• Active patients- good bone quality
• Osteoarthritis
• Avascular necrosis
• Steroids
• Trauma
• Alcohol use

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27 year old lady with SS disease - AVN
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Contraindication

• Infections
• Femoral neck fractures
• Osteoporosis
• Deformity inadequate bone stock
• Protrusio

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Femoral neck fracture absolute contra-indication
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Failed femoral neck fracture absolute
contra-indication
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Protrusio relative contra-indication
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Advantages of the procedure

• Pain relief about same as TJR
• Preservation of bone of the femoral head
• More normal gait femoral head mostly intact and
  leg length maintained
• Buys time and bone stock for younger patients
  who will face eventual revisions

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Advantages of the Procedure

• Less late dislocation risk
• More vigorous activities
• Large metal on metal articulation
• Fluid film lubrication optimized
• Less wear debris about 3 of amount of wear
  debris generated by polyethylene bearing surfaces

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Sports Resumption

• Narvani et al
• - 65 sports pre-surgery
• - 92 post-surgery
• - Increased frequency and intensity
  after surgery

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Survivorship Published Studies

• Daniel et al 5 year 99.8 in OA in lt 55 YO
  much better than Swedish registry
• Treacy et al 98 _at_ 5 yrs
• Lilikakis 98.6 _at_ 2 yrs
• Amstutz 97.8 _at_ 5 yrs in patients with good
  bone stock
• Hing et al 99.1 _at_ 3 yrs
• Nishii et al 96 _at_ 5 yrs
• Revell et al 93.2 _at_ 6.1 yrs in AVN patients

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Published Results

• Mont et al Gait Analysis More normal gait
  versus Standard THA
• Bell et al As easy to revise to standard THA as
  primary THA (femoral component)
• Mont et al 93 good and excellent in AVN, 98
  GE in OA
• Vail et al Better activity and motion vs THA,
  same complication and reoperation rates
• Vendittoli et al Acetabular bone resection
  equivalent SR vs Standard THA
• Vendittoli et al Leg length equality 86 vs THA
  60. Restoration of biomechanical measures
• Multiple Studies GE pain relief and function
  in almost all patients

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1 Problem in standard total joints is loosening!
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Complications

• Wound problems
• Hematoma, drainage, infections
• Femoral neck fracture 1-2 - up to 6 months
  post-op
• (1 men, 2 women)
• Dislocation uncommon despite less offset
  capability (after healed)
• Infection
• DVT
• Metal ions - Potential effects - Chromium and
  cobalt (excreted in the urine)

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Nishii et al. J Arthroplasty (176-83), February
2007

• Metal on Metal hip resurfacing
• 5 year revision-free survival rate 96
• 1/50 Femoral neck fracture
• 1/50 Septic loosening
• 1/50 Femoral component aseptic loosening

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Amstutz et a, J Bone Joint Surg (234-49), Sept
2006

• 400 metal on metal SR
• 4 year survivorship 94.4
• 7 loosening
• 3 femoral neck fractures

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Amstutz et alCORR Feb 2007 (Epub)

• SR in patients lt 50 years old
• 5 year survivorship 97.8 in patients with good
  bone quality

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Ronan Treacy

• 3000 BHRs - 2 Dislocations

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Ball, LeDuff Amstutz, JBJS (735-41), April 2007

• 21 conversions vs 64 Primary THR
• No differences
• Operative time
• Blood los
• Complications
• HHS
• UCLA Score
• SF - 12 Score
• Radiographs
• No dislocations
• Summary Comparable procedure and results

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Surgical Technique
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Postoperative Nursing

• Similar to care of the total joint patient
• Prevention of DVT medication, physical measures
  and early ambulation
• Watch for infection
• Catheters out quickly
• Assessment of home environment

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Postoperative Physical Therapy

• Surgical approach is usually posterior
• OOB the evening of the operative day or the next
  morning
• Pain management so ambulation is encouraged-
  crucial
• Usual precautions with bending, putting on
  clothes (some surgeons less stringent)- need OT
  instructions

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Post-Op Activity

• No sports for 6-12 months

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• WG Ward series
• 53 BHRs
• 51 Patients

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Gender

• Male 39
• Female - 12

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• Range Age 22 68
• Mean 48
• Median 50
• Mode - 47

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Diagnosis

• OA 38 hips patients
• AVN 15 hips, 13 patients

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BMI

• Range 19 - 42
• Mean 28.5
• Median 28.1

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Follow-Up

• Range 1-15 Months
• Mean 7.7 months

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Head Size

• 46 50 mm 40/53

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EBL

• Mean 337 mls

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LOSMean 2.84 days

• 1 day 4
• 2 days 31
• 3 days 9
• gt4 days 9

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Revisions

• 2/53
• Dislocation Cup revised
• Pain persisted femoral component revised to
  standard THR
• Anterior impingement cup migrated post-op -
  Recently revised cup

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Patient Satisfaction

• Subjective Primarily Good Excellent
• 2 dissatisfied - requiring revision

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Fractures Femoral Neck

• None in the first 53
• One in subsequent patients successfully
  converted to THR

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Oxford Hip Score Follow-Up Score Patients
name _________________________ Medical
record number _______________ Study Number
__________ Date form completed
_____/_____/_____ Date Of Surgery____/____/____
month day
year month day year
For the most recent 4 weeks 1. How would you
describe the pain you usually have in your
hip? 1? None 2? Very mild 3? Mild 4?
Moderate 5? Severe 2. Have you been troubled
by pain from your hip in bed at night? 1? No
nights 2? Only 1 or 2 nights 3? Some
nights 4? Most nights 5? Every night 3,
Have you had any sudden, severe pain (shooting,
stabbing, or spasms) from your affected hip? 1?
No days 2? Only 1 or 2 days 3? Some days 4?
Most days 5? Every day 4. Have you been
limping when walking because of your hip? 1?
Rarely/never 2? Sometimes or just at first 3?
Often, not just at first 4? Most of the
time 5? All of the time
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5. For how long have you been able to walk
before the pain in your hip becomes severe (with
or without a walking aid)? 1? No pain for 30
minutes or more 2? 16 to 30 minutes 3? 5 to
15 minutes 4? Around the house only 5? Not at
all 6. Have you been able to climb a flight of
stairs? 1? Yes, easily 2? With little
difficulty 3? With moderate difficulty 4?
With extreme difficulty 5? No, impossible 7.
Have you been able to put on a pair of socks,
stockings, or tights? 1? Yes, easily 2 With
little difficulty 3? With moderate
difficulty 4? With extreme difficulty 5? No,
impossible 8. After a meal (sat at a table), how
painful has it been for you to stand up from a
chair because of your hip? 1? Not at all
painful 2? Slightly painful 3? Moderately
painful 4? Very painful 5? Unbearable
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9. Have you had any trouble getting in and out
of a car or using public transportation because
of your hip? 1? No trouble at all 2? Very
little trouble 3? Moderate trouble 4? Extreme
difficulty 5? Impossible to do 10. Have you
had any trouble with washing and drying yourself
(all over) because of your hip? 1? No trouble
at all 2? Very little trouble 3? Moderate
trouble 4? Extreme difficulty 5? Impossible
to do 11. Could you do household shopping on
your own? 1? Yes, easily 2? With little
difficulty 3? With moderate difficulty 4?
With extreme difficulty 5? No, impossible 12.
How much has pain from your hip interfered with
your usual work, including housework? 1? Not at
all 2? A little bit 3? Moderately 4?
Greatly 5? Totally
Total Oxford Hip Score__
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Reference for Score  Dawson J, Fitzpatrick R,
Carr A, Murray D. Questionnaire on the
perceptions of patients about total hip
replacement. J Bone Joint Surg Br. 1996
Mar78(2)185-90.  Link
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Oxford Hip Score

• Points Pain Night Pain Sudden
  Pain Limp Walk
  Stairs
• 1. None No nights None
  Rarely None
  Easily
• 2. Very mild 1-2 nights 1-2 days
  Some 16-30 min
  A little
• 3. Mild Some Some
  Often 5-15 min
  Moderate
• 4. Mod Most Most
  Most House only
  Extreme
• 5. Severe Every Every
  Every Not at all
  Impossible

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Oxford Hip Score

• Points Socks First rising
  Car W ash/Dry Shopping
  Work
• 1. Easily None
  None None Easily
  None
• 2. A little Slight
  Little Little
  Little Little
• 3. Moderate Moderate
  Moderate Moderate Moderate
  Moderate
• 4. Extreme Very
  Extreme Extreme Extreme
  Greatly
• 5. Impossible Impossible
  Impossible Impossible Impossible
  Totally

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Oxford Hip Score

• Pre-Op Post-Op
  Improvement
• Mean (Avg) 44.0 19.7 23.0
• Median 44.0 18.0 24.0
• Mode 42.0 12.0 35.0
• p lt .0001

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Improvement in Oxford Hip Score

• Age p n.s.
• Gender p n.s.
• Diagnosis p n.s.
• Weight p n.s.
• BMI p .02
• Gender, after controlling for BMI

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BMI Oxford Hip Score

• BMI Avg Improvement
• 25 19
• 30 23
• 35 26
• 40 30
• p lt .0191

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Length of Stay

• Age p .0028
• BMI p .0144
• Weight p n.s.

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Unusual Cases

• Hardware avoidance
• Femoral shaft deformity
• Provides another option

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Personal Observation

• Most informed patient population
• Most inquisitive patient population
• Highest expectations
• Longest clinic visits

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William G. Ward Summary

• Less bone sacrifice
• More invasive more tissue dissection and
  releases to mobilize femur
• More surgery to recover from

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William G. Ward Summary

• Early-fast rehab for young active patients
• Not indicated for older patients
• Risk of femoral neck fracture
• More surgery to rehab from

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BHR

• Viable option
• Younger patient
• Active patient
• Preserve bone stock
• Less activity restrictions
• Another tool in your armamentarium

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Birmingham Hip Resurfacing

• Say yes
• Or send to Wake Forest

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Questions
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Thank You