I’m sorry, but resurfacing is the worst compromised head-neck ratio there is. I don’t understand the argument that it has improved range of motion. And probably the biggest fallacy is this proposed advantage of greater activity level and return to sports. I mean, it’s anecdotal and unproven. It’s hype over science. Quite frankly there’s massive patient selection and bias in the whole thing, and there’s not one blinded, randomized trial to show that.
Try to do resurfacing in a young, bulky male—it’s very difficult with that femoral head in place. As you can imagine, there are challenges with restoration of leg length if it’s short.
So, try if you can to avoid those patients. Avoid the patients that are osteopenic. Beware of the temptation of all women. That’s professionally speaking because, quite frankly, resurfacings have atrocious results in all women. If you’re a woman less than 40 when you have it, a 13% rate of revision has been reported.
Peter doesn’t do women and there is good reason for that.
Here’s Peter’s argument. ‘I’m only going to do a resurfacing in young males.’
All right. Let’s go through that. The data now debunks that.
The Australian Registry. The revision rate of males who have a total hip or resurfacing at 55 years of age, follow them for 10 years, a total hip is 5.4% and resurfacing—and that’s excluding the ones that have been recalled—is 6.7%. It is not lower in young males. That’s fallacy.
The Finnish Hip Registry demonstrated not a single hip resurfacing met our guidelines of a less than 5% revision rate at 10 years. Multiple hip systems do. And what’s not talked about is when a resurfacing fails, and you must do a revision, at Oxford the 10-year re-revision rate is 38%. In the Australian Registry, the 10-year re-revision rate, so once you’ve done the revision, 26% return for another revision.
In terms of cost, a resurfacing implant will cost most institutions significantly more than any alternate bearing, and that’s never discussed.
So truly, in my opinion, there is not a single reason to be performing resurfacings, except for one. The most compelling reason for resurfacing that I ever heard was from a good friend of mine who said, “Some patients have an emotional attachment to their proximal femoral bone.” I say, treat that with psychotherapy not with surgery.
Moderator Duncan: Excellent debate. Peter, I have a question for you. In the cases that are ideally aligned, we cannot recognize any edge loading, we are still seeing, it’s uncommon, cases of adverse local tissue reaction. Can you explain it in the male patient?
Dr. Brooks: Well, I can’t fully explain it, but there are some reports, for instance, of pseudo-tumors associated with the BHR that only looked at acetabular inclination. And one of the harder things to measure is acetabular anteversion. It’s like getting an X-ray of a fracture. If you need an A-P and a lateral it could look great in one and not in the other. And that’s been my problem when I’ve had adverse local tissue reactions. It hasn’t been due to inclination, it’s been due to anteversion and the way certain pelvises are more tipped back, which tends to edge load the anterior rim. There was a study out of England that looked, in coded form, at failures of resurfacing and wear properties and whether they were infected, fractured, dislocations or pseudo-tumors, the analyzers didn’t know. When they broke the code, all the pseudotumor patients had edge loading…all of them.
Moderator Duncan: Steve, if we were to change the materials successfully—not metal-on-metal any more, metal on something else such as poly or ceramic-on-ceramic—would you change your mind? Would there be a group of individuals you feel this would be suitable for?
Dr. MacDonald: No.
Moderator Duncan: Give us your thoughts, on surveillance after a patient has had one of these and he or she is quite happy with it. What surveillance do you follow at your institution Peter?
Dr. Brooks: I’m doing clinical visits at 1, 2, 5 and 10 years. Then I’ll be done.
Moderator Duncan: The question of ions and other things come up?
Dr. Brooks: We get ions and we get 3-dimensional imaging with MARS MRI in symptomatic patients.
Moderator Duncan: My last question for each of you, the patient has had one side done, is happy, wants to have the other side done. Do you feel compelled to get the ions and to get screening of the first side to see if the process is already underway? This patient has become sensitized to cobalt.
Dr. Brooks: I always get ion levels if I’m about to do the second side. More to be aware of it so that if there’s trouble 5 years later I know which side was the trouble maker.
Dr. MacDonald: I think that’s a good idea to get a baseline, a midline on the first side.
Moderator Duncan: We’ve come to the end of the discussion. Join me in thanking the debaters.
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Senior Editor: Jay D. Mabrey, M.D., whose 35 year career in orthopedics included residency at Duke University Medical Center, service in the United States Army Medical Corps, Fellowship at the Hospital for Special Surgery and a long, distinguished career at Baylor University Medical Center where, in addition to his overall leadership at that institution, developed the Joint Wellness Program that helped patients get up after surgery more quickly, developed the first virtual reality surgical simulator for knee arthroscopy and chaired the FDA Orthopaedic Device Panel, is Orthopedics This Week’s newest contributing writer and editor.
