| It was very interesting to watch the doctors present | | | | to guide the doctor in placement of the pin and find |
| from the doctors perspective but it is quite different | | | | the exact center of the femoral neck. |
| coming from our side. When we look at it as OUR | | | | Approaches were discussed and again there is |
| bodies they are cutting open, it changes the whole | | | | disagreement among the surgeons as to which |
| view. The following is my view as a patient. Vicky | | | | approach is better, the conclusion was the approach |
| This overview of the conference I attended in | | | | that works the best for the doctor to get the best |
| Belgium, June 25 - 28, 2008 are notes that I took | | | | results that doctor can get for his patient is the best |
| during the presentations and sessions as well as my | | | | approach to be used by that doctor. Dr. De Smet |
| own personal opinions and thoughts on the subject. It | | | | said during his live surgery via video feed that he |
| is in no way scientific data. To summarize the | | | | hated seeing patients of his coming in a year or two |
| conference in two sentences, I will quote Mr. McMinn, | | | | post op limping badly with a well placed prosthesis |
| one of the inventors of the BHR (Birmingham Hip | | | | due to having had an antero lateral approach and |
| Resurfacing device):Bad results of Resurfacings are | | | | damage to the gluteus medius muscle. |
| the result of badly done Resurfacing - Derek McMinn | | | | Neck capsule preservation, during De Smets live |
| Also I will quote Dr. Koen DeSmet a surgeon that has | | | | surgery he stressed the importance of NOT cutting |
| done more hip resurfacings than the majority of | | | | through the capsule, just release it to save |
| surgeons in the world. A WELL DONE resurfacing | | | | vascularity. Doctors that remove the soft tissue will |
| works well, but is TECHNICALLY DIFFICULT. - Koen | | | | see more neck notching. It was interesting to see |
| DeSmet McMinns quote was mentioned on several | | | | that many of the doctors on the panel DID remove |
| occasions throughout the conference and mainly has | | | | either the entire neck capsule or a large portion of it. |
| to do with the technical difficulty of resurfacing in | | | | Hopefully they will learn after this course the |
| general. It was clear to me again after attending my | | | | importance of preserving the neck capsule. |
| third orthopedic conference that the above | | | | Metal Ions |
| statement is SO true and was reinforced in several | | | | Jury is still out on this subject. Pat Campbell is now |
| of the sessions during this conference. It appears the | | | | independently doing implant retrieval studies. I believe |
| many problems that exist today with resurfacings | | | | any patient that is diagnosed with metal allergies as |
| have to do with the surgeon and technique. As with | | | | the cause of pain or ALVAL should insist that their |
| Real Estate the three important factors being | | | | doctor send their removed device to Pats lab for a |
| location, location, location, with hip resurfacing it is | | | | full study to find out for sure if that was indeed the |
| experience, experience, experience AND I will add to | | | | reason for failure. My concern is that there will be |
| that SKILL. | | | | doctors that have poorly placed devices that are |
| My thoughts: I know many newer patients that post | | | | causing impingement and higher metal wear and then |
| on the Yahoo Surface Hippy Message board and | | | | turning around and blaming it on metal allergies when |
| choose to go to newer surgeons or end up having | | | | it could be a reaction to high metal wear due to the |
| no choice due to financial matters or insurance | | | | malpositioned implant. It is easier to blame it on the |
| limitations get upset by those of us that keep | | | | patient than it is to accept the idea that the surgeon |
| repeating the importance of picking a surgeon with | | | | misplaced the device or notched the neck and the |
| experience. I wish these patients would just | | | | bone under the cap has collapsed as a result and it |
| understand that many of us take hours out of our | | | | has nothing to do with metal allergies. |
| every day lives to HELP people. Misguiding someone | | | | They do have lymphocyte tests now but they are |
| to a newer inexperienced surgeon is NOT my | | | | rare to find. Not sure what they will prove. I have |
| definition of helping someone. When the question is | | | | personally volunteered myself as a case study since I |
| asked, well then, who will be in a doctors first 100? I | | | | have extreme metal sensitivity and have had my |
| will tell you who, those that do not care to take the | | | | BHR now for over 3 years, so I am now past the 2 |
| time to research alternatives. Those like the guy I | | | | year danger zone for ALVAL to show up. |
| ran into that was scheduled for a THR and when I | | | | As far as metal ions on women of child bearing age, |
| told him about resurfacing his response was that his | | | | both Amstutz and De Smet agree on the fact that it |
| doctor did not do them and he trusted his doctor. | | | | should not be an issue for women of child bearing |
| The gal that posted a week or so ago saying she | | | | age where many doctors will not implant MoM (Metal |
| was having a THR in a few days and wanted to talk | | | | on Metal) resurfacings. The question is, are poly |
| to others that had been through it. I emailed her | | | | debris really any better for an unborn fetus? |
| offline and no matter what I told her, she was not | | | | Amstutz has had no evidence and has had patients |
| going to postpone her surgery that Monday, she was | | | | with high levels of metal sensitivity with no problems |
| just going to let her surgeon give her a THR. A | | | | showing up at all. Very important issue to keep in |
| surgeon that never even told her what resurfacing | | | | mind that there are TWO parts to the metal ions |
| even was and she was in her 30s! Well those are the | | | | discussion. |
| patients that can end up being in a doctors first 100, | | | | Wear related problem (Metallosis) is very different |
| the ones that go into a doctors office and just will | | | | than metal sensitivity. (Hypersensitivity, Inflammatory |
| listen to what they are told and end up with what | | | | lymphocytes) |
| they get. Like the poor woman many of us met at | | | | They have found that activity has NO correlation to |
| De Smets brunch in SF. She could barely walk with | | | | metal ions. |
| crutches because the Hemi-prosthesis with a large | | | | Problems with HRA |
| femoral stem device her doctor had placed inside her, | | | | · Impingement |
| De Smet flat out told her he would never use a | | | | · Socket problems |
| device like that on anyone unless it was a woman in | | | | The following was a slide regarding the conclusions |
| her late 90s that he knew was going to be | | | | drawn on metal ions. |
| wheelchair bound anyway and had very few years | | | | Conclusions |
| left to live. This woman was in her 40s and was | | | | · Significant differences between current |
| there to get a consult with De Smet. Last I heard, | | | | generation resurfacing devices |
| she is going to go back to the same doctor that did | | | | · Those differences are less important |
| that to her in the first place to fix it, if you can | | | | compared to the extreme high levels due to |
| believe that!As far as I am concerned, those that | | | | malpositioning of components |
| take the time to seek out information and find their | | | | · Some patients have elevated ion levels |
| way to the surface hippy message board or the | | | | preoperatively for unknown reason |
| referenced web site or email me offline for help, well | | | | · No correlation between ion levels and |
| they deserve to know the truth. Not MY truth but | | | | activity |
| the truth even all of the top surgeons speak. There | | | | · Correct positioning of components is crucial |
| IS a learning curve with hip resurfacing. HRA is a very | | | | Acetabuler Malposition Early problems - dislocation, |
| different procedure than a THR, completely different. | | | | Later problems Impingement |
| Now onto what I learned at the conference and my | | | | Lessons to be learned |
| notes. Dr. Amstutz - Technique - Crucial Overall the | | | | Component misalignment leads to increased - even |
| majority of the problems found in hip resurfacing are | | | | dramatic - wear |
| surgeon related. Cup malpositioning, femoral | | | | Not a gradual but a step increase |
| component placement off, can cause impingement, | | | | Positioning of implants (inclination, anteversion, relative |
| neck fractures, femoral neck thinning | | | | positioning) |
| Contraindications for hip resurfacing | | | | Very early failures: head |
| Age - Some doctors are still using age as a possible | | | | Later failures: cup (wear) Bursae |
| contraindication. It appears the more experience a | | | | Painful Resurfacing - Dr. Schmalzried lead this panel |
| surgeon has, the more open they are to taking cases | | | | discussion and started it off by saying, folks this |
| for older patients, some doctors will look only at a | | | | looks like we have very bad news here. From what |
| patients bone density - quality and not worry about | | | | he heard during the discussions, the biggest problem |
| age.Dr. Amstutz takes much older patients more and | | | | with resurfacings was a surgeon problem. It was all |
| more now. He is of the firm belief that eventually hip | | | | technical in nature. So again, back to McMinns quote |
| resurfacing will always be a first choice for any | | | | and back to what I and many others on the board |
| patient unless the condition of the patient warrants | | | | like Alan Ray, Chris Saunders and I say over and |
| otherwise.Dr. Amstutz began hip resurfacing 35 years | | | | over again, EXPERIENCE. The more experienced a |
| ago and in 1987 he started with large diameter heads. | | | | surgeon is the better your chances of a successful |
| He has done some patients that maybe should not | | | | resurfacing that will last you a lifetime with no |
| get resurfaced but if they request it, he will tell them | | | | problems of impingement or long term pain issues like |
| the risks and possibly still do it.My own personal | | | | ongoing groin pain, etc. |
| opinion - I was extremely impressed with Dr. | | | | Devices |
| Schmalzried, we spent a lot of time talking and | | | | There are a lot of different devices out there, each |
| debating the THR vs. Resurfacing issue. Overall I | | | | has its pluses and minuses. Apparently the Conserve |
| thought he added a lot to the whole conference and | | | | Plus, the Durom and the ASR device have stems |
| the sessions that he moderated, I felt he brought a | | | | proportionate to the device size. With the BHR the |
| nice balance to what could have turned into heated | | | | stem is the same exact size no matter what size the |
| debates, where he was able to bring the panels to | | | | component is. The smaller the femoral neck the |
| some form of agreement in a way that arrived at a | | | | smaller the stem needs to be for proper stress |
| conclusion for the surgeons that were there to learn | | | | shielding. With a component size smaller than a 42 |
| to allow them to take something away from that | | | | which is what I have, a BHR should not be used. So a |
| session and learn from it. Regarding my personal | | | | 40 or a 38 should always be used with one of the |
| conversations with Dr. S, I definitely agree with him | | | | other devices due to the stem size of the BHR. From |
| to a certain point, in that certain patients, THRs will | | | | what I understand the C+ device has not been |
| be a better option and solution for them. There are | | | | available in India therefore Dr. Bose uses the ASR in |
| three cases in particular that come to my mind. A | | | | these cases. Dr. De Smet chooses to use various |
| friend that I received permission from to post her | | | | different devices. He believes the best resurfacing |
| pictures from her surgery, | | | | devices out there right now are the BHR and the C+. |
| To see photos of one patient (very graphic on the | | | | You will see his explanation in his latest video |
| referenced website by clicking on Stories-43 year old | | | | interview that I did with him in Belgium. See the |
| female patient..) I must warn you, the photos are | | | | referenced website under Doctors>Video |
| extremely graphic images of live surgery. | | | | Interviews. The Wright C+ with its A class material |
| To show just how bad her bone quality was and | | | | that has recently been patented appears to have the |
| how advanced her AVN had become in such a short | | | | lowest metal wear of all the implants available out |
| period of time. Her femur literally fell apart like chalk | | | | there. Please watch Dr. Amstutz video interview for |
| during her surgery. There was just no way she was | | | | more information about the C+ device. The stem |
| going to get a BHR or even a BMHR, a large MoM | | | | also is smaller than the BHR stem and therefore it will |
| THR was her only option. She will indeed be very | | | | work better in smaller boned patients. Or patients |
| happy with it. Another case is the gal that posted on | | | | that have a narrower femoral neck sizes. |
| the Yahoo Message board a couple of months ago | | | | De Smets live surgery |
| that woke up hysterically when she found out she | | | | He keeps the patients blood pressure usually around |
| ended up with a THR because she felt it was the | | | | 60 - 65. There are so many steps he takes to make |
| end of her world as she knew it. Another young | | | | sure the patient gains the correct anatomy. |
| patient in his early thirties contacted me offline and I | | | | Measuring, re-measuring, angles, depths, placement, |
| emailed his x-rays to three doctors for their | | | | amounts removed to maintain equal leg lengths, |
| evaluations. One top doctor recommended THRs due | | | | neutral position of guide pin. Heterotopic ossification |
| to the patient's anatomy as well as several | | | | prevention, placing protective cloth to protect the |
| deformities in both his hips. Another top doc thought | | | | tissue from bone fragments, believe it or not, not all |
| maybe a 50/50 chance for resurfacing on one side | | | | doctors do that, just watch some of the live video |
| but a definite THR on the other. His comment was | | | | surgeries available online for viewing and you will see |
| that it does not make sense to give a patient a HRA | | | | the difference between sloppy and exceptional work. |
| if it does not restore the patient's anatomy. The third | | | | Removing osteophytes, if you do not remove them, |
| doctor also a top doctor said he would do his best to | | | | the patient will impinge. So some of you patients |
| preserve the patients bone stock due to his very | | | | complaining of pain might have had osteophytes that |
| young age, but since it was such an extremely | | | | the doctor left in you. Again, the importance of |
| difficult case, he could not say until he got inside for | | | | picking an experienced surgeon for this. De Smet has |
| sure what would be the best for the patient. One | | | | revised around 63-65 malpositioned resurfacings done |
| thing I have learned out of my past 3+ years of | | | | by other doctors. Dr. De Smet now uses a smaller |
| experience posting on this board and speaking to | | | | incision than he used to, about half the size he did |
| probably close to 1000 patients and many top | | | | before. |
| surgeons is that we as a group have such a passion | | | | Rehab |
| for hip resurfacing as in many ways we should BUT, | | | | Dr. De Smet came across pool therapy quite by |
| we need to keep in mind that it is not a one size fits | | | | accident. He found that his patients were going into |
| all solution. | | | | the pool at the Holiday Inn with a special waterproof |
| One Industry professional, Martyn, made a point that | | | | STERILE bandage and they were recovering at a |
| there should be a device for each individual patient, | | | | much quicker pace than ever before. This is the |
| and that device should be the best solution for them. | | | | reason for him adopting this in his post op rehab |
| Whether it be an HRA a device similar to a BMHR or | | | | protocol now and for Hugo starting the Villa for aqua |
| a THR. The part that I disagree with when it came | | | | therapy sessions beginning day two post op for all |
| to my debate/discussion with Schmalzried is that my | | | | patients. |
| belief is similar to Amstutz which is the same as De | | | | Dr. Kim in Ottawa does not encourage running or high |
| Smet, Bose, Su, McMinn, Treacy (I believe it is | | | | impact for any of his patients. |
| anyway) that each individual patient should be | | | | Amstutz believes a patient can do anything with their |
| treated as that, a unique individual and evaluated on | | | | implant, it will just have a shorter life of the implant |
| what their anatomy, bone quality activity level, etc. is. | | | | the same way you would wear a normal hip with |
| A doctor should not say all women over 55, | | | | higher impact, you will also wear a metal hip or the |
| immediately turn down and without even looking at | | | | bone around it. |
| the x-rays say a THR would be the better option | | | | The following were taken off of slides that were |
| that I strongly disagree with. So to summarize, I | | | | presented that I took a picture of: |
| have a whole new level of respect for Dr. Thomas | | | | Anesthesiologist |
| Schmalzried after spending a considerable amount of | | | | Blood transfusion |
| time speaking with him. I agree with him on many | | | | 2004 5.9% |
| things he says but the one area that we will need to | | | | 2005 5.1% control hypertension |
| agree to disagree is where that line is drawn as to | | | | 2006 2.5% Cell saver |
| which patients should be resurfaced and which ones | | | | 2007 1.0% Tranexamic acid |
| should not. He is an excellent surgeon, I have no | | | | MM Resurfacing |
| doubt about that as well as his dedication to | | | | Conserve Plus |
| providing his patients with the best possible care and | | | | Technique changes |
| outcome, but if you have a difficult case or are a | | | | 3rd Generation (current technique n=329) |
| female over age 55, I would think about going to a | | | | · Intertrochanteric suction (since 1/04) |
| different doctor. If you are a female under 55, a | | | | · Carbojet (since 4/04) |
| healthy active male in his 40s with a straight case of | | | | · Thin shells (since 10/03) |
| OA, then by all means Dr. S would make an excellent | | | | · Larger chamfer (Europeanc remaing |
| choice." Correction here - I received an email from Dr. | | | | -170°) |
| Schmalzried that states his position is as follows on | | | | · Cementing stem for large (>1cm) cysts |
| July 16, 2008 | | | | only and small component size Uncemented |
| I have resurfaced women in their 60s and men in | | | | Amstutz worries about the coating on the stem of |
| their 70s. Age is not the salient criteria - but a | | | | the Cormet device still cause head stress shielding, |
| surrogate for bone density and life expectancy on a | | | | one of the panel members brought up that wouldn't |
| population basis. Each patient has to be evaluated | | | | you say the same about your method of cementing |
| individually to assess the benefit-to-risk ratio of | | | | the stem? He said he does not see it as the same, |
| resurfacing v. THR for them. - Thomas P. | | | | that he sees cementing the stem as just part of |
| Schmalzried, M.D. | | | | being a filler. He did a series of a blind study of 400 |
| On the subject of Learning Curves | | | | controlled group half stems cemented half |
| The really experienced surgeons all admitted that | | | | uncemented and so far no difference between the |
| they are STILL learning today. Dr. Amstutz, Dr. De | | | | two. Not one failure yet in a cemented stem some |
| Smet, Dr. OHara, all have done well over 1000 hip | | | | going on 8 years. Now he just only cements the |
| resurfacings and they all agree that the learning curve | | | | stem on patients he would otherwise do a THR on. |
| continues. Amstutz made the comment that NO two | | | | On cementless he says there has to be a perfect fit |
| femoral heads are the same. | | | | between the bone and the component. The |
| This technology is still in its infant stages and they | | | | consensus on cemented is that it is fine. The |
| are still perfecting the devices, the instrumentation, | | | | foundation of bone needs to be good enough for |
| the placement of the cups, the angles of the | | | | cementless. There was a whole discussion on cement |
| components, the soft tissue preservation methods, | | | | mantle thickness that went into a lot of detail. You |
| the incision sizes, the anesthesia, the rehab protocols. | | | | can see the slides later on Pat's website under Dr. |
| Some mentioned that the newer doctors do have | | | | Schmalzrieds presentations. |
| the advantage of learning from doctors that have | | | | To summarize the whole conference, again, I will |
| gone before them to avoid the same mistakes. I | | | | quote Derek McMinn and Koen De Smet |
| agree to some point, but even though they KNOW | | | | Bad results of Resurfacings are the result of bad |
| what causes notching of the femoral neck, why is it | | | | Resurfacing - Derek McMinn |
| that some newer doctors still notch? It is inevitable | | | | A WELL DONE resurfacing works well, but is |
| that the first few times they do something, even | | | | TECHNICALLY DIFFICULT. - Koen DeSmet |
| though they know to avoid certain things, until they | | | | Go to an experienced surgeon that has no problem |
| get the hang of it, they WILL make mistakes. Even | | | | continuing their education on technique and will |
| some of the greats today will still make mistakes | | | | continue to learn from other doctors by attending |
| now and then, after all, they are only human. But the | | | | these conferences and sharing what they have |
| odds are, the more experience a doctor has, the less | | | | learned. |
| mistakes he will make. Again, Dr. Su in his video | | | | Ask your doctor about experience and continued |
| interview near the end explains the learning curve in | | | | education on hip resurfacing. A LOT of new |
| stages really well. Go to Dr. Sus video interview to | | | | advances have come about and unless the doctors |
| where the clock says around 3 minutes near the end | | | | are coming to these courses and learning them, there |
| on the referenced website under Doctors - Video | | | | is no way they could possibly know. Send them to |
| Interviews. | | | | this link and tell them they need to sign up for this |
| Instrumentation was discussed and it looks like many | | | | online. There was a ton of info presented at this |
| of the companies are coming out with better and | | | | conference and it is all available to them now. Click on |
| better instrumentation. With some of the designs it | | | | the second referenced site to visit the Advanced |
| makes it nearly impossible for a doctor to notch a | | | | Course Resurfacing website |
| neck due to the way the instrumentation is designed | | | | And...that sums up this patients perspective. |