Re: Hip Resurfacing - a UK docs perspective

[Guest guest]

-This post is very helpful. I had a l total hip in 04 & I need a r hip resurf

or total replacement very soon. I would like further technical details about

best options, i.e. which MOM material to choose, I have heard that biomet is the

best, and how long do resurfs last vs. thr's? If anyone knows these answers, I

will be truly greatful.

thanks!

-- In Joint Replacement , " vicky4vi " <vickymm@...> wrote:

>

> This is a direct copy and paste from a U.K. message board called HipsRUs. All

about hips, Mark Bloomfield is the moderator and founder of that group and an

orthopedic surgeon/consultant as they call them over there. Very interesting

read for those still looking into options for hip surgery.

>

> Mark: " Have not been here for a while, but thought it time to post something,

especially after attending the recent British Hip Society meeting in Manchester.

>

> Which, by the way, was poorly attended by what would be regarded as the doyens

of UK hip surgery. Mostly new consultants, registrars or other 'training'

grades. Not sure why. Maybe everyone is feeling fatigued by the credit crunch,

the declining state of the NHS etc.

>

> I have now done over 1000 hip resurfacings. Practically all the Birmingham

device marketed by & Nephew. So I thought I would share what I think about

the technique right now. This is not a scientific paper and the views expressed

are my own. I suppose I could 'prove' most of what is written below by suitable

references in the literature, but some is instinct or gut feel. So it could be

wrong, but chances are high the views expressed are accurate!

>

> The 2 perceived 'flaws' or catches to metal-on-metal [MOM] hip resurfacing

revolve around metal ion reactions on the part of the patient, and neck of femur

fracture / collapse below the femoral component [the cap]. I have also had 3 cup

failures where the device worked itself loose and tilted. These were probably my

'fault' as I did not realize they were poorly fixed at the time of the original

surgery. It is easy to be fooled and I am now much more careful about testing

the 'fix' of the cup to bone. If I have the slightest doubt, I augment the

fixation with screws.

>

> Taking each of the 2 perceived flaws in turn:

>

> 1. The metal ion story. This is potentially the most serious and; if you

paranoid or fearful; the most worrying aspect of all MOM devices, be they

resurfacings or Total Hip Replacements [THRs]. The concern is two-fold. First

that metal ions may cause an allergic-type reaction [but NOT the same kind of

allergy as a skin rash to cheap jewellery!] and second that they may cause

cellular or chromosomal anomalies that may lead to an increased risk of cancers.

>

> MOM devices are not new. At the time Charnley developed his metal on

polyethylene [plastic] hip replacement, McKee and Farrar in Norwich were

attempting to perfect a MOM THR, many examples of which have survived to last 30

yrs or more. But there were so many early failures of the McKee-Farrar that it

was eventually abandoned. This is NOT because MOM bearings are rubbish, but

because the technology to make the bearings a perfect fit every time was not

available. Those McKee-Farrars that were a perfect match and were implanted

favourably, are the ones that lasted 2, 3 or more decades. In contrast, almost

all Charnley metal on polyethylene hips started failing at 15 to 18 years, if

not before. So metal on polyethylene does better at first, but is worse in the

long run as compared to the 'best' McKee-Farrars.

> Ring, at Redhill in Surrey, developed a MOM THR which he placed in huge

numbers - several thousand. Again, those that were a perfect match lasted a vey

long time and most patients died with them in situ. But there were too many

early failures if the fit was not perfect and Ring moved to polyethylene like

Charnley. Ring metal on polyethylene hips did very badly - even worse than his

MOM device or the Charnley version. He was later asked and recounted how he

bitterly regretted moving away from MOM, but metal on polyethylene was the

irresistible fashion at the time. So be aware that fads or fashions influence

orthopaedic surgeons as well!

>

> There are various other MOM THRs that came and went over the years. Most died

out after being placed in relatively small numbers. In the early 90s, Sulzer [a

prosthetic manufacturer] heavily promoted their Metasul MOM THR. This was

machined with modern techniques to ensure an accurate fit every time. The

results were good, but there was a significant percentage of unexplained pain

and fluid-filled cyst formation which I now believe to be due to metal debris.

The Metasul bearing was too small and the metallurgy not quite right to achieve

'fluid film' lubrication.

>

> The point of all the above is to show that we have a combined clinical history

of various MOM devices stretching over hundreds of thousands of patient-years.

There is not a shred of epidemiological evidence that MOM devices cause an

increased risk of cancer or other serious disease. There is, however, plenty of

evidence that MOM bearings only work reliably if they are a) of large, rather

than small diameter. In other words, the bigger the MOM bearing, the better.

they are machined to be a perfect fit every time. That takes specialised

knowledge and machinery. c) they are made of the right metal alloy, prepared and

finished in the right way. d) they are implanted in near perfect position

>

> When McMinn perfected his MOM resurfacing [the BHR], he knew where to go for

the metal alloy he needed. He went to the men that made Ring's sucessful

MOM THRs. Some say McMinn was lucky. I say he instinctively knew the Ring hip

alloy and the exact clearance that Ring was aiming for was the right one. Other

makers of MOM hip resurfacing devices thought they could 'improve' the McMinn

device. They were universally wrong. So be careful, some MOM hip resurfacings

are [in my opinion] not as good as the S & N product. Some are only slightly

worse. Others are truly terrible. I cannot say which here, as could be sued for

libel!

>

> When it comes to positioning in the body, this is also crucial. This is the

factor that most depends on the surgeons insight, experience and innate ability

to work well with tissues or bone. To be done well the operation needs good

exposure and adequate releases. Doing this SAFELY is a knack some learn easily

and quickly, some more slowly and some not at all. Hip resurfacing must be done

perfectly or nearly perfectly every time to be reliable. It does not forgive

errors that would be seen as relatively minor in the context of THR. It is why I

am very, very wary of 'mini incision' resurfacing. Wounds heal side to side, not

end to end. They hurt from end to end, but that is usually temporary! As a

result of my website and hipsrus, have seen a number of patients unhappy with

their resurfacings. Almost all had mal-positioned cups. The other problem is

that plain x-rays nearly always under-estimate or 'hide' the true extent of

mal-positioning. Bad position = increased metal ion formation = pain and

inflammation. True 'allergy' seems exceptionally rare and skin patch testing is

useless for detecting this. Ditto the test.

>

> 2. The fracture neck of femur story. This is also a question of surgeon

experience, technical skill and judgement. I have done both hips [bHR] in a

woman who is now 84. She is exceptional and should not be seen as the rule. In

my first 500 resurfacings, I had 5 fractures I know about. There could have been

1 or 2 more that occurred after I left the NHS. In the last 500, there has not

been a single fracture, despite doing patients that other surgeons would dismiss

out of hand. So it is a combination of physiological not chronological age,

surgeon technique, bone quality and aftercare that allows hip resurfacing to be

done 'out of the box' . Much has been written about the surgical approach and

fractures. I.e. anterior, posterior, trochanter detachment etc. It is a sterile

debate as it largely does not matter. DESPITE research that suggests it does. It

just shows how research or theory and practice do not always match. But the

trochanter detachment causes too many problems for me to adopt it. Non-union,

painful screws, bursitis etc. It also takes more time and this is a cardinal sin

as operation time and infection rates are directly correlated. The quicker,

slicker the operation - whilst respecting safety - the lower the infection rate.

>

> What is not widely recognised are the more subtle advantages of resurfacing.

THR invades the femoral bone canal and embolises the fatty marrow into the

bloodstream. This marrow is filtered by the lungs but it still causes a reaction

that is generally considered harmful. This effect is greatly reduced by

resurfacing. So I notice how - in general- resurfacing patients bounce back from

surgery quicker and have fewer metabolic complications or reactions. Resurfacing

preserves your own bone and we probably do not yet fully understand the neural

or tiny nerve network in bone. Too many of my colleagues regard bone as

essentially inert or stupid. It is not. It knows the difference between

resurfacing and having its head amputated, then a great piece of metal and/or

cement shoved none too gently down its throat! So resurfacing feels more natural

in a way that is difficult or impossible to quantify scientifically. And all the

research and literature is based on scoring systems that cannot fully measure

this.

>

> Then there are the issues of offset, leg length and version. No time to go

into detail, but all are easier to get right with BHR.

>

> The alternatives to resurfacing are not without their own unique problems.

Ceramic-on-ceramic can break. Or squeak. So loudly the patient is constantly

embarrased. It is also a very hard bearing couple with no 'give' at all. MOM

resurfacing has a tiny amount of give that makes all the difference because it

is one metal surface 'floating ' on another. It can slightly absorb shocks by

displacing the fluid. The hip bones do not likle ceramic-ceramic and they never

fully adapt. Again the effect is very subtle and the patient is usually so

grateful to be free of pain and able to walk that scientists cannot measure the

slight downside. Do not get me wrong, I do use ceramic-ceramic when I cannot

resurface with MOM. But it is not my first choice.

>

> Metal or ceramic on polyethylene THR is improving. Newer 'cross-linked'

polyethylene looks promising as it wears less than the older versions. BUT and

this is a big but, we have been here before and been disappointed by newer

'improved' polyethylene. There was a disastrous 'improved' polyethylene a few

years back. Not sure of name but relieved to tell you I never used it. Whatever

you do, plastic remains plastic. I prefer metal wherever possible. I hear a

ceramic on ceramic resurfacing is being developed. I hope it does not suffer

from the present drawbacks of ceramics.

>

> Resurfacing cannot correct every pre-operative deformity. So some patients are

unsuitable even if bone quality is OK. Knowing who can and who can't be

resurfaced for this reason goes back to surgeon intuition.

>

> So in summary:

>

> I like to resurface whenever I think it will work. Based only loosely on

CHRONOLOGICAL age or SEX. It is physiological age and activity that counts. It

seems it is never a bad idea to preserve bone if this can be done with a low

risk of complications related to resurfacing.

>

> Much of the critical press vs resurfacing is hopelessly ill-informed. And

there is some hysteria emerging, much like the MMR vaccine scare. It is a

difficult operation to do well and the learning curve is not steep. It is flat,

so getting really skilled takes time.

>

> 'Bad' MOM bearings, either because mal-positioned or wrong metallurgy/design

are occasionally seriously destructive of surrounding tissues. Such hips need

revising sooner rather than later. Diagnosing what is wrong early and accurately

is important. Knowing how to fix the situation even more so.

>

> Men do better with BHR than women for 2 reasons. First their bone is generally

stronger. Men are resistant to osteoporosis. Second, their hips are larger so

the bigger bearings are less likely to suffer if slightly mal-positioned. But

all other things being equal, I believe there is no difference between the sexes

and therefore excluding women from having BHR is nonsense. It does mean that

large women with small bones and small hips are a particular technical challenge

to get it near perfect! Hence no apologies for making a really big incision in

this group.

>

> Hope this helps. Email me directly if queries or comments. And before

you ask, yes please cross-post to other fora. But verbatim please, as the

disclaimers are legally important.

>

> Mark. "

>

> Hope it helps those of you still searching.

>

> Vicky

>

[Guest guest]

Hi ,

No one knows how long a resurface will last, just like there is no way a doc can

tell you how long any THR will last. But, what I can tell you is that there is

now 12 years history of the exxisting BHR device which is the Birmingham Hip

Resurfacing device. That device has the longest and proven track record. Mark

Bloomfield speaks of it in his article and prefers using that device over any

others due to the track record and data on it. The very first prototype of the

BHR was implanted in a gal named in 1991 and hers is going on almost 18

years now. You can read copies of her posts here.

http://www.surfacehippyinfo.com/Hip-Stories/20090321408/Other-Patients/-Ell\

is/menu-id-30.html

I can also tell you that my surgeon told me there is no reason my BHR shouldn't

last me the rest of my life, I was 48 when I had mine implanted over 3 years

ago. There is a lot more info on this site

http://www.surfacehippyinfo.com/

I recommend reading the home page and the articles on it to start. Feel free to

email me offline as well if you have any questions, my email is vickymm@

comcast.net, just delete the space.

Vicky

LBHR Dr. Bose Dec 01 05

> >

> > This is a direct copy and paste from a U.K. message board called HipsRUs.

All about hips, Mark Bloomfield is the moderator and founder of that group and

an orthopedic surgeon/consultant as they call them over there. Very interesting

read for those still looking into options for hip surgery.

> >

> > Mark: " Have not been here for a while, but thought it time to post

something, especially after attending the recent British Hip Society meeting in

Manchester.

> >

> > Which, by the way, was poorly attended by what would be regarded as the

doyens of UK hip surgery. Mostly new consultants, registrars or other 'training'

grades. Not sure why. Maybe everyone is feeling fatigued by the credit crunch,

the declining state of the NHS etc.

> >

> > I have now done over 1000 hip resurfacings. Practically all the Birmingham

device marketed by & Nephew. So I thought I would share what I think about

the technique right now. This is not a scientific paper and the views expressed

are my own. I suppose I could 'prove' most of what is written below by suitable

references in the literature, but some is instinct or gut feel. So it could be

wrong, but chances are high the views expressed are accurate!

> >

> > The 2 perceived 'flaws' or catches to metal-on-metal [MOM] hip resurfacing

revolve around metal ion reactions on the part of the patient, and neck of femur

fracture / collapse below the femoral component [the cap]. I have also had 3 cup

failures where the device worked itself loose and tilted. These were probably my

'fault' as I did not realize they were poorly fixed at the time of the original

surgery. It is easy to be fooled and I am now much more careful about testing

the 'fix' of the cup to bone. If I have the slightest doubt, I augment the

fixation with screws.

> >

> > Taking each of the 2 perceived flaws in turn:

> >

> > 1. The metal ion story. This is potentially the most serious and; if you

paranoid or fearful; the most worrying aspect of all MOM devices, be they

resurfacings or Total Hip Replacements [THRs]. The concern is two-fold. First

that metal ions may cause an allergic-type reaction [but NOT the same kind of

allergy as a skin rash to cheap jewellery!] and second that they may cause

cellular or chromosomal anomalies that may lead to an increased risk of cancers.

> >

> > MOM devices are not new. At the time Charnley developed his metal on

polyethylene [plastic] hip replacement, McKee and Farrar in Norwich were

attempting to perfect a MOM THR, many examples of which have survived to last 30

yrs or more. But there were so many early failures of the McKee-Farrar that it

was eventually abandoned. This is NOT because MOM bearings are rubbish, but

because the technology to make the bearings a perfect fit every time was not

available. Those McKee-Farrars that were a perfect match and were implanted

favourably, are the ones that lasted 2, 3 or more decades. In contrast, almost

all Charnley metal on polyethylene hips started failing at 15 to 18 years, if

not before. So metal on polyethylene does better at first, but is worse in the

long run as compared to the 'best' McKee-Farrars.

> > Ring, at Redhill in Surrey, developed a MOM THR which he placed in

huge numbers - several thousand. Again, those that were a perfect match lasted a

vey long time and most patients died with them in situ. But there were too many

early failures if the fit was not perfect and Ring moved to polyethylene like

Charnley. Ring metal on polyethylene hips did very badly - even worse than his

MOM device or the Charnley version. He was later asked and recounted how he

bitterly regretted moving away from MOM, but metal on polyethylene was the

irresistible fashion at the time. So be aware that fads or fashions influence

orthopaedic surgeons as well!

> >

> > There are various other MOM THRs that came and went over the years. Most

died out after being placed in relatively small numbers. In the early 90s,

Sulzer [a prosthetic manufacturer] heavily promoted their Metasul MOM THR. This

was machined with modern techniques to ensure an accurate fit every time. The

results were good, but there was a significant percentage of unexplained pain

and fluid-filled cyst formation which I now believe to be due to metal debris.

The Metasul bearing was too small and the metallurgy not quite right to achieve

'fluid film' lubrication.

> >

> > The point of all the above is to show that we have a combined clinical

history of various MOM devices stretching over hundreds of thousands of

patient-years. There is not a shred of epidemiological evidence that MOM devices

cause an increased risk of cancer or other serious disease. There is, however,

plenty of evidence that MOM bearings only work reliably if they are a) of large,

rather than small diameter. In other words, the bigger the MOM bearing, the

better. they are machined to be a perfect fit every time. That takes

specialised knowledge and machinery. c) they are made of the right metal alloy,

prepared and finished in the right way. d) they are implanted in near perfect

position

> >

> > When McMinn perfected his MOM resurfacing [the BHR], he knew where to go for

the metal alloy he needed. He went to the men that made Ring's sucessful

MOM THRs. Some say McMinn was lucky. I say he instinctively knew the Ring hip

alloy and the exact clearance that Ring was aiming for was the right one. Other

makers of MOM hip resurfacing devices thought they could 'improve' the McMinn

device. They were universally wrong. So be careful, some MOM hip resurfacings

are [in my opinion] not as good as the S & N product. Some are only slightly

worse. Others are truly terrible. I cannot say which here, as could be sued for

libel!

> >

> > When it comes to positioning in the body, this is also crucial. This is the

factor that most depends on the surgeons insight, experience and innate ability

to work well with tissues or bone. To be done well the operation needs good

exposure and adequate releases. Doing this SAFELY is a knack some learn easily

and quickly, some more slowly and some not at all. Hip resurfacing must be done

perfectly or nearly perfectly every time to be reliable. It does not forgive

errors that would be seen as relatively minor in the context of THR. It is why I

am very, very wary of 'mini incision' resurfacing. Wounds heal side to side, not

end to end. They hurt from end to end, but that is usually temporary! As a

result of my website and hipsrus, have seen a number of patients unhappy with

their resurfacings. Almost all had mal-positioned cups. The other problem is

that plain x-rays nearly always under-estimate or 'hide' the true extent of

mal-positioning. Bad position = increased metal ion formation = pain and

inflammation. True 'allergy' seems exceptionally rare and skin patch testing is

useless for detecting this. Ditto the test.

> >

> > 2. The fracture neck of femur story. This is also a question of surgeon

experience, technical skill and judgement. I have done both hips [bHR] in a

woman who is now 84. She is exceptional and should not be seen as the rule. In

my first 500 resurfacings, I had 5 fractures I know about. There could have been

1 or 2 more that occurred after I left the NHS. In the last 500, there has not

been a single fracture, despite doing patients that other surgeons would dismiss

out of hand. So it is a combination of physiological not chronological age,

surgeon technique, bone quality and aftercare that allows hip resurfacing to be

done 'out of the box' . Much has been written about the surgical approach and

fractures. I.e. anterior, posterior, trochanter detachment etc. It is a sterile

debate as it largely does not matter. DESPITE research that suggests it does. It

just shows how research or theory and practice do not always match. But the

trochanter detachment causes too many problems for me to adopt it. Non-union,

painful screws, bursitis etc. It also takes more time and this is a cardinal sin

as operation time and infection rates are directly correlated. The quicker,

slicker the operation - whilst respecting safety - the lower the infection rate.

> >

> > What is not widely recognised are the more subtle advantages of resurfacing.

THR invades the femoral bone canal and embolises the fatty marrow into the

bloodstream. This marrow is filtered by the lungs but it still causes a reaction

that is generally considered harmful. This effect is greatly reduced by

resurfacing. So I notice how - in general- resurfacing patients bounce back from

surgery quicker and have fewer metabolic complications or reactions. Resurfacing

preserves your own bone and we probably do not yet fully understand the neural

or tiny nerve network in bone. Too many of my colleagues regard bone as

essentially inert or stupid. It is not. It knows the difference between

resurfacing and having its head amputated, then a great piece of metal and/or

cement shoved none too gently down its throat! So resurfacing feels more natural

in a way that is difficult or impossible to quantify scientifically. And all the

research and literature is based on scoring systems that cannot fully measure

this.

> >

> > Then there are the issues of offset, leg length and version. No time to go

into detail, but all are easier to get right with BHR.

> >

> > The alternatives to resurfacing are not without their own unique problems.

Ceramic-on-ceramic can break. Or squeak. So loudly the patient is constantly

embarrased. It is also a very hard bearing couple with no 'give' at all. MOM

resurfacing has a tiny amount of give that makes all the difference because it

is one metal surface 'floating ' on another. It can slightly absorb shocks by

displacing the fluid. The hip bones do not likle ceramic-ceramic and they never

fully adapt. Again the effect is very subtle and the patient is usually so

grateful to be free of pain and able to walk that scientists cannot measure the

slight downside. Do not get me wrong, I do use ceramic-ceramic when I cannot

resurface with MOM. But it is not my first choice.

> >

> > Metal or ceramic on polyethylene THR is improving. Newer 'cross-linked'

polyethylene looks promising as it wears less than the older versions. BUT and

this is a big but, we have been here before and been disappointed by newer

'improved' polyethylene. There was a disastrous 'improved' polyethylene a few

years back. Not sure of name but relieved to tell you I never used it. Whatever

you do, plastic remains plastic. I prefer metal wherever possible. I hear a

ceramic on ceramic resurfacing is being developed. I hope it does not suffer

from the present drawbacks of ceramics.

> >

> > Resurfacing cannot correct every pre-operative deformity. So some patients

are unsuitable even if bone quality is OK. Knowing who can and who can't be

resurfaced for this reason goes back to surgeon intuition.

> >

> > So in summary:

> >

> > I like to resurface whenever I think it will work. Based only loosely on

CHRONOLOGICAL age or SEX. It is physiological age and activity that counts. It

seems it is never a bad idea to preserve bone if this can be done with a low

risk of complications related to resurfacing.

> >

> > Much of the critical press vs resurfacing is hopelessly ill-informed. And

there is some hysteria emerging, much like the MMR vaccine scare. It is a

difficult operation to do well and the learning curve is not steep. It is flat,

so getting really skilled takes time.

> >

> > 'Bad' MOM bearings, either because mal-positioned or wrong metallurgy/design

are occasionally seriously destructive of surrounding tissues. Such hips need

revising sooner rather than later. Diagnosing what is wrong early and accurately

is important. Knowing how to fix the situation even more so.

> >

> > Men do better with BHR than women for 2 reasons. First their bone is

generally stronger. Men are resistant to osteoporosis. Second, their hips are

larger so the bigger bearings are less likely to suffer if slightly

mal-positioned. But all other things being equal, I believe there is no

difference between the sexes and therefore excluding women from having BHR is

nonsense. It does mean that large women with small bones and small hips are a

particular technical challenge to get it near perfect! Hence no apologies for

making a really big incision in this group.

> >

> > Hope this helps. Email me directly if queries or comments. And before

you ask, yes please cross-post to other fora. But verbatim please, as the

disclaimers are legally important.

> >

> > Mark. "

> >

> > Hope it helps those of you still searching.

> >

> > Vicky

> >

>

[Guest guest]

> Hi ,

This is an addendum to Vicky's post about her BHR & longevity. I've had mine

since October of 2006 & have BEATEN THE CRAP OUT OF THEM. I work as a

carpenter/contractor, climb ladders with loads up to 70 Lbs, kneel, squat &

stand, push, pull & carry all sorts of things. The only problems I'm having is

the knees, ankles, & various other supporting joints & bones are having a bit of

a hard time keeping up with working as hard as I like to. I've waterskied,

danced, all sorts of stuff, my 2 year check up the doc said I can do anything I

want to now. I've noticed no problem in the prostheses ever.

Hope this helps.

Peace

Bilateral BHR, Hozack, 10/17-31/06

[Guest guest]

thank you - that helps a lot.  It gives me hope.  I have jra, so my local docs

are telling me that resurfacing may not be an option for me, because I have a

small 'neck' in my hip & osteoporosis & they're afraid of breakage, however, I

haven't ruled it out yet.  Life is made for second opinions.  Does Birmingham

make a thr model?

thanks!  

________________________________

From: vicky4vi <vickymm@...>

Joint Replacement

Sent: Tuesday, April 21, 2009 2:14:55 PM

Subject: Re: Hip Resurfacing - a UK docs perspective

Hi ,

No one knows how long a resurface will last, just like there is no way a doc can

tell you how long any THR will last. But, what I can tell you is that there is

now 12 years history of the exxisting BHR device which is the Birmingham Hip

Resurfacing device. That device has the longest and proven track record. Mark

Bloomfield speaks of it in his article and prefers using that device over any

others due to the track record and data on it. The very first prototype of the

BHR was implanted in a gal named in 1991 and hers is going on almost 18

years now. You can read copies of her posts here.

http://www.surfaceh ippyinfo. com/Hip-Stories/ 20090321408/ Other-Patients/

-Ellis/ menu-id-30. html

I can also tell you that my surgeon told me there is no reason my BHR shouldn't

last me the rest of my life, I was 48 when I had mine implanted over 3 years

ago. There is a lot more info on this site

http://www.surfaceh ippyinfo. com/

I recommend reading the home page and the articles on it to start. Feel free to

email me offline as well if you have any questions, my email is vickymm@

comcast.net, just delete the space.

Vicky

LBHR Dr. Bose Dec 01 05

> >

> > This is a direct copy and paste from a U.K. message board called HipsRUs.

All about hips, Mark Bloomfield is the moderator and founder of that group and

an orthopedic surgeon/consultant as they call them over there. Very interesting

read for those still looking into options for hip surgery.

> >

> > Mark: " Have not been here for a while, but thought it time to post

something, especially after attending the recent British Hip Society meeting in

Manchester.

> >

> > Which, by the way, was poorly attended by what would be regarded as the

doyens of UK hip surgery. Mostly new consultants, registrars or other 'training'

grades. Not sure why. Maybe everyone is feeling fatigued by the credit crunch,

the declining state of the NHS etc.

> >

> > I have now done over 1000 hip resurfacings. Practically all the Birmingham

device marketed by & Nephew. So I thought I would share what I think about

the technique right now. This is not a scientific paper and the views expressed

are my own. I suppose I could 'prove' most of what is written below by suitable

references in the literature, but some is instinct or gut feel. So it could be

wrong, but chances are high the views expressed are accurate!

> >

> > The 2 perceived 'flaws' or catches to metal-on-metal [MOM] hip resurfacing

revolve around metal ion reactions on the part of the patient, and neck of femur

fracture / collapse below the femoral component [the cap]. I have also had 3 cup

failures where the device worked itself loose and tilted. These were probably my

'fault' as I did not realize they were poorly fixed at the time of the original

surgery. It is easy to be fooled and I am now much more careful about testing

the 'fix' of the cup to bone. If I have the slightest doubt, I augment the

fixation with screws.

> >

> > Taking each of the 2 perceived flaws in turn:

> >

> > 1. The metal ion story. This is potentially the most serious and; if you

paranoid or fearful; the most worrying aspect of all MOM devices, be they

resurfacings or Total Hip Replacements [THRs]. The concern is two-fold. First

that metal ions may cause an allergic-type reaction [but NOT the same kind of

allergy as a skin rash to cheap jewellery!] and second that they may cause

cellular or chromosomal anomalies that may lead to an increased risk of cancers.

> >

> > MOM devices are not new. At the time Charnley developed his metal on

polyethylene [plastic] hip replacement, McKee and Farrar in Norwich were

attempting to perfect a MOM THR, many examples of which have survived to last 30

yrs or more. But there were so many early failures of the McKee-Farrar that it

was eventually abandoned. This is NOT because MOM bearings are rubbish, but

because the technology to make the bearings a perfect fit every time was not

available. Those McKee-Farrars that were a perfect match and were implanted

favourably, are the ones that lasted 2, 3 or more decades. In contrast, almost

all Charnley metal on polyethylene hips started failing at 15 to 18 years, if

not before. So metal on polyethylene does better at first, but is worse in the

long run as compared to the 'best' McKee-Farrars.

> > Ring, at Redhill in Surrey, developed a MOM THR which he placed in

huge numbers - several thousand. Again, those that were a perfect match lasted a

vey long time and most patients died with them in situ. But there were too many

early failures if the fit was not perfect and Ring moved to polyethylene like

Charnley. Ring metal on polyethylene hips did very badly - even worse than his

MOM device or the Charnley version. He was later asked and recounted how he

bitterly regretted moving away from MOM, but metal on polyethylene was the

irresistible fashion at the time. So be aware that fads or fashions influence

orthopaedic surgeons as well!

> >

> > There are various other MOM THRs that came and went over the years. Most

died out after being placed in relatively small numbers. In the early 90s,

Sulzer [a prosthetic manufacturer] heavily promoted their Metasul MOM THR. This

was machined with modern techniques to ensure an accurate fit every time. The

results were good, but there was a significant percentage of unexplained pain

and fluid-filled cyst formation which I now believe to be due to metal debris.

The Metasul bearing was too small and the metallurgy not quite right to achieve

'fluid film' lubrication.

> >

> > The point of all the above is to show that we have a combined clinical

history of various MOM devices stretching over hundreds of thousands of

patient-years. There is not a shred of epidemiological evidence that MOM devices

cause an increased risk of cancer or other serious disease. There is, however,

plenty of evidence that MOM bearings only work reliably if they are a) of large,

rather than small diameter. In other words, the bigger the MOM bearing, the

better. they are machined to be a perfect fit every time. That takes

specialised knowledge and machinery. c) they are made of the right metal alloy,

prepared and finished in the right way. d) they are implanted in near perfect

position

> >

> > When McMinn perfected his MOM resurfacing [the BHR], he knew where to go for

the metal alloy he needed. He went to the men that made Ring's sucessful

MOM THRs. Some say McMinn was lucky. I say he instinctively knew the Ring hip

alloy and the exact clearance that Ring was aiming for was the right one. Other

makers of MOM hip resurfacing devices thought they could 'improve' the McMinn

device. They were universally wrong. So be careful, some MOM hip resurfacings

are [in my opinion] not as good as the S & N product. Some are only slightly

worse. Others are truly terrible. I cannot say which here, as could be sued for

libel!

> >

> > When it comes to positioning in the body, this is also crucial. This is the

factor that most depends on the surgeons insight, experience and innate ability

to work well with tissues or bone. To be done well the operation needs good

exposure and adequate releases. Doing this SAFELY is a knack some learn easily

and quickly, some more slowly and some not at all. Hip resurfacing must be done

perfectly or nearly perfectly every time to be reliable. It does not forgive

errors that would be seen as relatively minor in the context of THR. It is why I

am very, very wary of 'mini incision' resurfacing. Wounds heal side to side, not

end to end. They hurt from end to end, but that is usually temporary! As a

result of my website and hipsrus, have seen a number of patients unhappy with

their resurfacings. Almost all had mal-positioned cups. The other problem is

that plain x-rays nearly always under-estimate or 'hide' the true extent of

mal-positioning. Bad

position = increased metal ion formation = pain and inflammation. True

'allergy' seems exceptionally rare and skin patch testing is useless for

detecting this. Ditto the test.

> >

> > 2. The fracture neck of femur story. This is also a question of surgeon

experience, technical skill and judgement. I have done both hips [bHR] in a

woman who is now 84. She is exceptional and should not be seen as the rule. In

my first 500 resurfacings, I had 5 fractures I know about. There could have been

1 or 2 more that occurred after I left the NHS. In the last 500, there has not

been a single fracture, despite doing patients that other surgeons would dismiss

out of hand. So it is a combination of physiological not chronological age,

surgeon technique, bone quality and aftercare that allows hip resurfacing to be

done 'out of the box' . Much has been written about the surgical approach and

fractures. I.e. anterior, posterior, trochanter detachment etc. It is a sterile

debate as it largely does not matter. DESPITE research that suggests it does. It

just shows how research or theory and practice do not always match. But the

trochanter detachment

causes too many problems for me to adopt it. Non-union, painful screws,

bursitis etc. It also takes more time and this is a cardinal sin as operation

time and infection rates are directly correlated. The quicker, slicker the

operation - whilst respecting safety - the lower the infection rate.

> >

> > What is not widely recognised are the more subtle advantages of resurfacing.

THR invades the femoral bone canal and embolises the fatty marrow into the

bloodstream. This marrow is filtered by the lungs but it still causes a reaction

that is generally considered harmful. This effect is greatly reduced by

resurfacing. So I notice how - in general- resurfacing patients bounce back from

surgery quicker and have fewer metabolic complications or reactions. Resurfacing

preserves your own bone and we probably do not yet fully understand the neural

or tiny nerve network in bone. Too many of my colleagues regard bone as

essentially inert or stupid. It is not. It knows the difference between

resurfacing and having its head amputated, then a great piece of metal and/or

cement shoved none too gently down its throat! So resurfacing feels more natural

in a way that is difficult or impossible to quantify scientifically. And all the

research and literature is based

on scoring systems that cannot fully measure this.

> >

> > Then there are the issues of offset, leg length and version. No time to go

into detail, but all are easier to get right with BHR.

> >

> > The alternatives to resurfacing are not without their own unique problems.

Ceramic-on-ceramic can break. Or squeak. So loudly the patient is constantly

embarrased. It is also a very hard bearing couple with no 'give' at all. MOM

resurfacing has a tiny amount of give that makes all the difference because it

is one metal surface 'floating ' on another. It can slightly absorb shocks by

displacing the fluid. The hip bones do not likle ceramic-ceramic and they never

fully adapt. Again the effect is very subtle and the patient is usually so

grateful to be free of pain and able to walk that scientists cannot measure the

slight downside. Do not get me wrong, I do use ceramic-ceramic when I cannot

resurface with MOM. But it is not my first choice.

> >

> > Metal or ceramic on polyethylene THR is improving. Newer 'cross-linked'

polyethylene looks promising as it wears less than the older versions. BUT and

this is a big but, we have been here before and been disappointed by newer

'improved' polyethylene. There was a disastrous 'improved' polyethylene a few

years back. Not sure of name but relieved to tell you I never used it. Whatever

you do, plastic remains plastic. I prefer metal wherever possible. I hear a

ceramic on ceramic resurfacing is being developed. I hope it does not suffer

from the present drawbacks of ceramics.

> >

> > Resurfacing cannot correct every pre-operative deformity. So some patients

are unsuitable even if bone quality is OK. Knowing who can and who can't be

resurfaced for this reason goes back to surgeon intuition.

> >

> > So in summary:

> >

> > I like to resurface whenever I think it will work. Based only loosely on

CHRONOLOGICAL age or SEX. It is physiological age and activity that counts. It

seems it is never a bad idea to preserve bone if this can be done with a low

risk of complications related to resurfacing.

> >

> > Much of the critical press vs resurfacing is hopelessly ill-informed. And

there is some hysteria emerging, much like the MMR vaccine scare. It is a

difficult operation to do well and the learning curve is not steep. It is flat,

so getting really skilled takes time.

> >

> > 'Bad' MOM bearings, either because mal-positioned or wrong metallurgy/design

are occasionally seriously destructive of surrounding tissues. Such hips need

revising sooner rather than later. Diagnosing what is wrong early and accurately

is important. Knowing how to fix the situation even more so.

> >

> > Men do better with BHR than women for 2 reasons. First their bone is

generally stronger.. Men are resistant to osteoporosis. Second, their hips are

larger so the bigger bearings are less likely to suffer if slightly

mal-positioned. But all other things being equal, I believe there is no

difference between the sexes and therefore excluding women from having BHR is

nonsense. It does mean that large women with small bones and small hips are a

particular technical challenge to get it near perfect! Hence no apologies for

making a really big incision in this group.

> >

> > Hope this helps. Email me directly if queries or comments. And before

you ask, yes please cross-post to other fora. But verbatim please, as the

disclaimers are legally important..

> >

> > Mark. "

> >

> > Hope it helps those of you still searching.

> >

> > Vicky

> >

>

[Guest guest]

- Thank you for sharing that, it was information I needed to hear.  I am

totally psyched for you & inspired!  I hope someday to be telling your story &

dancing your dance!

Peace -

________________________________

From: <flotsam@...>

Joint Replacement

Sent: Wednesday, April 22, 2009 12:10:05 PM

Subject: Re: Hip Resurfacing - a UK docs perspective

> Hi ,

This is an addendum to Vicky's post about her BHR & longevity. I've had mine

since October of 2006 & have BEATEN THE CRAP OUT OF THEM. I work as a

carpenter/contracto r, climb ladders with loads up to 70 Lbs, kneel, squat &

stand, push, pull & carry all sorts of things. The only problems I'm having is

the knees, ankles, & various other supporting joints & bones are having a bit of

a hard time keeping up with working as hard as I like to. I've waterskied,

danced, all sorts of stuff, my 2 year check up the doc said I can do anything I

want to now. I've noticed no problem in the prostheses ever.

Hope this helps.

Peace

Bilateral BHR, Hozack, 10/17-31/06

[Guest guest]

I have two BHR, (each hip) and i feel fantastic!

THRs in March 2009.

> > >

> > > This is a direct copy and paste from a U.K. message board called HipsRUs.

All about hips, Mark Bloomfield is the moderator and founder of that group and

an orthopedic surgeon/consultant as they call them over there. Very interesting

read for those still looking into options for hip surgery.

> > >

> > > Mark: " Have not been here for a while, but thought it time to post

something, especially after attending the recent British Hip Society meeting in

Manchester.

> > >

> > > Which, by the way, was poorly attended by what would be regarded as the

doyens of UK hip surgery. Mostly new consultants, registrars or other 'training'

grades. Not sure why. Maybe everyone is feeling fatigued by the credit crunch,

the declining state of the NHS etc.

> > >

> > > I have now done over 1000 hip resurfacings. Practically all the Birmingham

device marketed by & Nephew. So I thought I would share what I think about

the technique right now. This is not a scientific paper and the views expressed

are my own. I suppose I could 'prove' most of what is written below by suitable

references in the literature, but some is instinct or gut feel. So it could be

wrong, but chances are high the views expressed are accurate!

> > >

> > > The 2 perceived 'flaws' or catches to metal-on-metal [MOM] hip resurfacing

revolve around metal ion reactions on the part of the patient, and neck of femur

fracture / collapse below the femoral component [the cap]. I have also had 3 cup

failures where the device worked itself loose and tilted. These were probably my

'fault' as I did not realize they were poorly fixed at the time of the original

surgery. It is easy to be fooled and I am now much more careful about testing

the 'fix' of the cup to bone. If I have the slightest doubt, I augment the

fixation with screws.

> > >

> > > Taking each of the 2 perceived flaws in turn:

> > >

> > > 1. The metal ion story. This is potentially the most serious and; if you

paranoid or fearful; the most worrying aspect of all MOM devices, be they

resurfacings or Total Hip Replacements [THRs]. The concern is two-fold. First

that metal ions may cause an allergic-type reaction [but NOT the same kind of

allergy as a skin rash to cheap jewellery!] and second that they may cause

cellular or chromosomal anomalies that may lead to an increased risk of cancers.

> > >

> > > MOM devices are not new. At the time Charnley developed his metal on

polyethylene [plastic] hip replacement, McKee and Farrar in Norwich were

attempting to perfect a MOM THR, many examples of which have survived to last 30

yrs or more. But there were so many early failures of the McKee-Farrar that it

was eventually abandoned. This is NOT because MOM bearings are rubbish, but

because the technology to make the bearings a perfect fit every time was not

available. Those McKee-Farrars that were a perfect match and were implanted

favourably, are the ones that lasted 2, 3 or more decades. In contrast, almost

all Charnley metal on polyethylene hips started failing at 15 to 18 years, if

not before. So metal on polyethylene does better at first, but is worse in the

long run as compared to the 'best' McKee-Farrars.

> > > Ring, at Redhill in Surrey, developed a MOM THR which he placed in

huge numbers - several thousand. Again, those that were a perfect match lasted a

vey long time and most patients died with them in situ. But there were too many

early failures if the fit was not perfect and Ring moved to polyethylene like

Charnley. Ring metal on polyethylene hips did very badly - even worse than his

MOM device or the Charnley version. He was later asked and recounted how he

bitterly regretted moving away from MOM, but metal on polyethylene was the

irresistible fashion at the time. So be aware that fads or fashions influence

orthopaedic surgeons as well!

> > >

> > > There are various other MOM THRs that came and went over the years. Most

died out after being placed in relatively small numbers. In the early 90s,

Sulzer [a prosthetic manufacturer] heavily promoted their Metasul MOM THR. This

was machined with modern techniques to ensure an accurate fit every time. The

results were good, but there was a significant percentage of unexplained pain

and fluid-filled cyst formation which I now believe to be due to metal debris.

The Metasul bearing was too small and the metallurgy not quite right to achieve

'fluid film' lubrication.

> > >

> > > The point of all the above is to show that we have a combined clinical

history of various MOM devices stretching over hundreds of thousands of

patient-years. There is not a shred of epidemiological evidence that MOM devices

cause an increased risk of cancer or other serious disease. There is, however,

plenty of evidence that MOM bearings only work reliably if they are a) of large,

rather than small diameter. In other words, the bigger the MOM bearing, the

better. they are machined to be a perfect fit every time. That takes

specialised knowledge and machinery. c) they are made of the right metal alloy,

prepared and finished in the right way. d) they are implanted in near perfect

position

> > >

> > > When McMinn perfected his MOM resurfacing [the BHR], he knew where to go

for the metal alloy he needed. He went to the men that made Ring's

sucessful MOM THRs. Some say McMinn was lucky. I say he instinctively knew the

Ring hip alloy and the exact clearance that Ring was aiming for was the right

one. Other makers of MOM hip resurfacing devices thought they could 'improve'

the McMinn device. They were universally wrong. So be careful, some MOM hip

resurfacings are [in my opinion] not as good as the S & N product. Some are only

slightly worse. Others are truly terrible. I cannot say which here, as could be

sued for libel!

> > >

> > > When it comes to positioning in the body, this is also crucial. This is

the factor that most depends on the surgeons insight, experience and innate

ability to work well with tissues or bone. To be done well the operation needs

good exposure and adequate releases. Doing this SAFELY is a knack some learn

easily and quickly, some more slowly and some not at all. Hip resurfacing must

be done perfectly or nearly perfectly every time to be reliable. It does not

forgive errors that would be seen as relatively minor in the context of THR. It

is why I am very, very wary of 'mini incision' resurfacing. Wounds heal side to

side, not end to end. They hurt from end to end, but that is usually temporary!

As a result of my website and hipsrus, have seen a number of patients unhappy

with their resurfacings. Almost all had mal-positioned cups. The other problem

is that plain x-rays nearly always under-estimate or 'hide' the true extent of

mal-positioning. Bad

> position = increased metal ion formation = pain and inflammation. True

'allergy' seems exceptionally rare and skin patch testing is useless for

detecting this. Ditto the test.

> > >

> > > 2. The fracture neck of femur story. This is also a question of surgeon

experience, technical skill and judgement. I have done both hips [bHR] in a

woman who is now 84. She is exceptional and should not be seen as the rule. In

my first 500 resurfacings, I had 5 fractures I know about. There could have been

1 or 2 more that occurred after I left the NHS. In the last 500, there has not

been a single fracture, despite doing patients that other surgeons would dismiss

out of hand. So it is a combination of physiological not chronological age,

surgeon technique, bone quality and aftercare that allows hip resurfacing to be

done 'out of the box' . Much has been written about the surgical approach and

fractures. I.e. anterior, posterior, trochanter detachment etc. It is a sterile

debate as it largely does not matter. DESPITE research that suggests it does. It

just shows how research or theory and practice do not always match. But the

trochanter detachment

> causes too many problems for me to adopt it. Non-union, painful screws,

bursitis etc. It also takes more time and this is a cardinal sin as operation

time and infection rates are directly correlated. The quicker, slicker the

operation - whilst respecting safety - the lower the infection rate.

> > >

> > > What is not widely recognised are the more subtle advantages of

resurfacing. THR invades the femoral bone canal and embolises the fatty marrow

into the bloodstream. This marrow is filtered by the lungs but it still causes a

reaction that is generally considered harmful. This effect is greatly reduced by

resurfacing. So I notice how - in general- resurfacing patients bounce back from

surgery quicker and have fewer metabolic complications or reactions. Resurfacing

preserves your own bone and we probably do not yet fully understand the neural

or tiny nerve network in bone. Too many of my colleagues regard bone as

essentially inert or stupid. It is not. It knows the difference between

resurfacing and having its head amputated, then a great piece of metal and/or

cement shoved none too gently down its throat! So resurfacing feels more natural

in a way that is difficult or impossible to quantify scientifically. And all the

research and literature is based

> on scoring systems that cannot fully measure this.

> > >

> > > Then there are the issues of offset, leg length and version. No time to go

into detail, but all are easier to get right with BHR.

> > >

> > > The alternatives to resurfacing are not without their own unique problems.

Ceramic-on-ceramic can break. Or squeak. So loudly the patient is constantly

embarrased. It is also a very hard bearing couple with no 'give' at all. MOM

resurfacing has a tiny amount of give that makes all the difference because it

is one metal surface 'floating ' on another. It can slightly absorb shocks by

displacing the fluid. The hip bones do not likle ceramic-ceramic and they never

fully adapt. Again the effect is very subtle and the patient is usually so

grateful to be free of pain and able to walk that scientists cannot measure the

slight downside. Do not get me wrong, I do use ceramic-ceramic when I cannot

resurface with MOM. But it is not my first choice.

> > >

> > > Metal or ceramic on polyethylene THR is improving. Newer 'cross-linked'

polyethylene looks promising as it wears less than the older versions. BUT and

this is a big but, we have been here before and been disappointed by newer

'improved' polyethylene. There was a disastrous 'improved' polyethylene a few

years back. Not sure of name but relieved to tell you I never used it. Whatever

you do, plastic remains plastic. I prefer metal wherever possible. I hear a

ceramic on ceramic resurfacing is being developed. I hope it does not suffer

from the present drawbacks of ceramics.

> > >

> > > Resurfacing cannot correct every pre-operative deformity. So some patients

are unsuitable even if bone quality is OK. Knowing who can and who can't be

resurfaced for this reason goes back to surgeon intuition.

> > >

> > > So in summary:

> > >

> > > I like to resurface whenever I think it will work. Based only loosely on

CHRONOLOGICAL age or SEX. It is physiological age and activity that counts. It

seems it is never a bad idea to preserve bone if this can be done with a low

risk of complications related to resurfacing.

> > >

> > > Much of the critical press vs resurfacing is hopelessly ill-informed. And

there is some hysteria emerging, much like the MMR vaccine scare. It is a

difficult operation to do well and the learning curve is not steep. It is flat,

so getting really skilled takes time.

> > >

> > > 'Bad' MOM bearings, either because mal-positioned or wrong

metallurgy/design are occasionally seriously destructive of surrounding tissues.

Such hips need revising sooner rather than later. Diagnosing what is wrong early

and accurately is important. Knowing how to fix the situation even more so.

> > >

> > > Men do better with BHR than women for 2 reasons. First their bone is

generally stronger.. Men are resistant to osteoporosis. Second, their hips are

larger so the bigger bearings are less likely to suffer if slightly

mal-positioned. But all other things being equal, I believe there is no

difference between the sexes and therefore excluding women from having BHR is

nonsense. It does mean that large women with small bones and small hips are a

particular technical challenge to get it near perfect! Hence no apologies for

making a really big incision in this group.

> > >

> > > Hope this helps. Email me directly if queries or comments. And

before you ask, yes please cross-post to other fora. But verbatim please, as the

disclaimers are legally important..

> > >

> > > Mark. "

> > >

> > > Hope it helps those of you still searching.

> > >

> > > Vicky

> > >

> >

>

>

>

>

>

>

>

>

[Guest guest]

Yes they do, it is a large head Metal on Metal implant. Martha and Mark

Cuban have one. Mark danced on dancing with the stars with his large MoM THR

only weeks out from his surgery. If you do not qualify for hip resurfacing, the

large head MoM is the best THR option IMO. There is also a BMHR device that is

not yet approved by the FDA. You can see an x-ray of all three options here

http://www.surfacehippyinfo.com/Options/Options/menu-id-51.html

Vicky

LBHR Dr. Bose Dec 01 05

> > >

> > > This is a direct copy and paste from a U.K. message board called HipsRUs.

All about hips, Mark Bloomfield is the moderator and founder of that group and

an orthopedic surgeon/consultant as they call them over there. Very interesting

read for those still looking into options for hip surgery.

> > >

> > > Mark: " Have not been here for a while, but thought it time to post

something, especially after attending the recent British Hip Society meeting in

Manchester.

> > >

> > > Which, by the way, was poorly attended by what would be regarded as the

doyens of UK hip surgery. Mostly new consultants, registrars or other 'training'

grades. Not sure why. Maybe everyone is feeling fatigued by the credit crunch,

the declining state of the NHS etc.

> > >

> > > I have now done over 1000 hip resurfacings. Practically all the Birmingham

device marketed by & Nephew. So I thought I would share what I think about

the technique right now. This is not a scientific paper and the views expressed

are my own. I suppose I could 'prove' most of what is written below by suitable

references in the literature, but some is instinct or gut feel. So it could be

wrong, but chances are high the views expressed are accurate!

> > >

> > > The 2 perceived 'flaws' or catches to metal-on-metal [MOM] hip resurfacing

revolve around metal ion reactions on the part of the patient, and neck of femur

fracture / collapse below the femoral component [the cap]. I have also had 3 cup

failures where the device worked itself loose and tilted. These were probably my

'fault' as I did not realize they were poorly fixed at the time of the original

surgery. It is easy to be fooled and I am now much more careful about testing

the 'fix' of the cup to bone. If I have the slightest doubt, I augment the

fixation with screws.

> > >

> > > Taking each of the 2 perceived flaws in turn:

> > >

> > > 1. The metal ion story. This is potentially the most serious and; if you

paranoid or fearful; the most worrying aspect of all MOM devices, be they

resurfacings or Total Hip Replacements [THRs]. The concern is two-fold. First

that metal ions may cause an allergic-type reaction [but NOT the same kind of

allergy as a skin rash to cheap jewellery!] and second that they may cause

cellular or chromosomal anomalies that may lead to an increased risk of cancers.

> > >

> > > MOM devices are not new. At the time Charnley developed his metal on

polyethylene [plastic] hip replacement, McKee and Farrar in Norwich were

attempting to perfect a MOM THR, many examples of which have survived to last 30

yrs or more. But there were so many early failures of the McKee-Farrar that it

was eventually abandoned. This is NOT because MOM bearings are rubbish, but

because the technology to make the bearings a perfect fit every time was not

available. Those McKee-Farrars that were a perfect match and were implanted

favourably, are the ones that lasted 2, 3 or more decades. In contrast, almost

all Charnley metal on polyethylene hips started failing at 15 to 18 years, if

not before. So metal on polyethylene does better at first, but is worse in the

long run as compared to the 'best' McKee-Farrars.

> > > Ring, at Redhill in Surrey, developed a MOM THR which he placed in

huge numbers - several thousand. Again, those that were a perfect match lasted a

vey long time and most patients died with them in situ. But there were too many

early failures if the fit was not perfect and Ring moved to polyethylene like

Charnley. Ring metal on polyethylene hips did very badly - even worse than his

MOM device or the Charnley version. He was later asked and recounted how he

bitterly regretted moving away from MOM, but metal on polyethylene was the

irresistible fashion at the time. So be aware that fads or fashions influence

orthopaedic surgeons as well!

> > >

> > > There are various other MOM THRs that came and went over the years. Most

died out after being placed in relatively small numbers. In the early 90s,

Sulzer [a prosthetic manufacturer] heavily promoted their Metasul MOM THR. This

was machined with modern techniques to ensure an accurate fit every time. The

results were good, but there was a significant percentage of unexplained pain

and fluid-filled cyst formation which I now believe to be due to metal debris.

The Metasul bearing was too small and the metallurgy not quite right to achieve

'fluid film' lubrication.

> > >

> > > The point of all the above is to show that we have a combined clinical

history of various MOM devices stretching over hundreds of thousands of

patient-years. There is not a shred of epidemiological evidence that MOM devices

cause an increased risk of cancer or other serious disease. There is, however,

plenty of evidence that MOM bearings only work reliably if they are a) of large,

rather than small diameter. In other words, the bigger the MOM bearing, the

better. they are machined to be a perfect fit every time. That takes

specialised knowledge and machinery. c) they are made of the right metal alloy,

prepared and finished in the right way. d) they are implanted in near perfect

position

> > >

> > > When McMinn perfected his MOM resurfacing [the BHR], he knew where to go

for the metal alloy he needed. He went to the men that made Ring's

sucessful MOM THRs. Some say McMinn was lucky. I say he instinctively knew the

Ring hip alloy and the exact clearance that Ring was aiming for was the right

one. Other makers of MOM hip resurfacing devices thought they could 'improve'

the McMinn device. They were universally wrong. So be careful, some MOM hip

resurfacings are [in my opinion] not as good as the S & N product. Some are only

slightly worse. Others are truly terrible. I cannot say which here, as could be

sued for libel!

> > >

> > > When it comes to positioning in the body, this is also crucial. This is

the factor that most depends on the surgeons insight, experience and innate

ability to work well with tissues or bone. To be done well the operation needs

good exposure and adequate releases. Doing this SAFELY is a knack some learn

easily and quickly, some more slowly and some not at all. Hip resurfacing must

be done perfectly or nearly perfectly every time to be reliable. It does not

forgive errors that would be seen as relatively minor in the context of THR. It

is why I am very, very wary of 'mini incision' resurfacing. Wounds heal side to

side, not end to end. They hurt from end to end, but that is usually temporary!

As a result of my website and hipsrus, have seen a number of patients unhappy

with their resurfacings. Almost all had mal-positioned cups. The other problem

is that plain x-rays nearly always under-estimate or 'hide' the true extent of

mal-positioning. Bad

> position = increased metal ion formation = pain and inflammation. True

'allergy' seems exceptionally rare and skin patch testing is useless for

detecting this. Ditto the test.

> > >

> > > 2. The fracture neck of femur story. This is also a question of surgeon

experience, technical skill and judgement. I have done both hips [bHR] in a

woman who is now 84. She is exceptional and should not be seen as the rule. In

my first 500 resurfacings, I had 5 fractures I know about. There could have been

1 or 2 more that occurred after I left the NHS. In the last 500, there has not

been a single fracture, despite doing patients that other surgeons would dismiss

out of hand. So it is a combination of physiological not chronological age,

surgeon technique, bone quality and aftercare that allows hip resurfacing to be

done 'out of the box' . Much has been written about the surgical approach and

fractures. I.e. anterior, posterior, trochanter detachment etc. It is a sterile

debate as it largely does not matter. DESPITE research that suggests it does. It

just shows how research or theory and practice do not always match. But the

trochanter detachment

> causes too many problems for me to adopt it. Non-union, painful screws,

bursitis etc. It also takes more time and this is a cardinal sin as operation

time and infection rates are directly correlated. The quicker, slicker the

operation - whilst respecting safety - the lower the infection rate.

> > >

> > > What is not widely recognised are the more subtle advantages of

resurfacing. THR invades the femoral bone canal and embolises the fatty marrow

into the bloodstream. This marrow is filtered by the lungs but it still causes a

reaction that is generally considered harmful. This effect is greatly reduced by

resurfacing. So I notice how - in general- resurfacing patients bounce back from

surgery quicker and have fewer metabolic complications or reactions. Resurfacing

preserves your own bone and we probably do not yet fully understand the neural

or tiny nerve network in bone. Too many of my colleagues regard bone as

essentially inert or stupid. It is not. It knows the difference between

resurfacing and having its head amputated, then a great piece of metal and/or

cement shoved none too gently down its throat! So resurfacing feels more natural

in a way that is difficult or impossible to quantify scientifically. And all the

research and literature is based

> on scoring systems that cannot fully measure this.

> > >

> > > Then there are the issues of offset, leg length and version. No time to go

into detail, but all are easier to get right with BHR.

> > >

> > > The alternatives to resurfacing are not without their own unique problems.

Ceramic-on-ceramic can break. Or squeak. So loudly the patient is constantly

embarrased. It is also a very hard bearing couple with no 'give' at all. MOM

resurfacing has a tiny amount of give that makes all the difference because it

is one metal surface 'floating ' on another. It can slightly absorb shocks by

displacing the fluid. The hip bones do not likle ceramic-ceramic and they never

fully adapt. Again the effect is very subtle and the patient is usually so

grateful to be free of pain and able to walk that scientists cannot measure the

slight downside. Do not get me wrong, I do use ceramic-ceramic when I cannot

resurface with MOM. But it is not my first choice.

> > >

> > > Metal or ceramic on polyethylene THR is improving. Newer 'cross-linked'

polyethylene looks promising as it wears less than the older versions. BUT and

this is a big but, we have been here before and been disappointed by newer

'improved' polyethylene. There was a disastrous 'improved' polyethylene a few

years back. Not sure of name but relieved to tell you I never used it. Whatever

you do, plastic remains plastic. I prefer metal wherever possible. I hear a

ceramic on ceramic resurfacing is being developed. I hope it does not suffer

from the present drawbacks of ceramics.

> > >

> > > Resurfacing cannot correct every pre-operative deformity. So some patients

are unsuitable even if bone quality is OK. Knowing who can and who can't be

resurfaced for this reason goes back to surgeon intuition.

> > >

> > > So in summary:

> > >

> > > I like to resurface whenever I think it will work. Based only loosely on

CHRONOLOGICAL age or SEX. It is physiological age and activity that counts. It

seems it is never a bad idea to preserve bone if this can be done with a low

risk of complications related to resurfacing.

> > >

> > > Much of the critical press vs resurfacing is hopelessly ill-informed. And

there is some hysteria emerging, much like the MMR vaccine scare. It is a

difficult operation to do well and the learning curve is not steep. It is flat,

so getting really skilled takes time.

> > >

> > > 'Bad' MOM bearings, either because mal-positioned or wrong

metallurgy/design are occasionally seriously destructive of surrounding tissues.

Such hips need revising sooner rather than later. Diagnosing what is wrong early

and accurately is important. Knowing how to fix the situation even more so.

> > >

> > > Men do better with BHR than women for 2 reasons. First their bone is

generally stronger.. Men are resistant to osteoporosis. Second, their hips are

larger so the bigger bearings are less likely to suffer if slightly

mal-positioned. But all other things being equal, I believe there is no

difference between the sexes and therefore excluding women from having BHR is

nonsense. It does mean that large women with small bones and small hips are a

particular technical challenge to get it near perfect! Hence no apologies for

making a really big incision in this group.

> > >

> > > Hope this helps. Email me directly if queries or comments. And

before you ask, yes please cross-post to other fora. But verbatim please, as the

disclaimers are legally important..

> > >

> > > Mark. "

> > >

> > > Hope it helps those of you still searching.

> > >

> > > Vicky

> > >

> >

>

>

>

>

>

>

>

>

[Guest guest]

Sorry to say, the BHR did not work for us... :-((

had it put in left hip in Dec 2006, it worked at first, easy recovery, no

restrictions on activity, she was rock scrabbling in the west less than a year

after surgery. She has had increasing difficulty walking for the past year,

blamed it on her known bad right knee. She just had a total knee put in Mar 16

2009, it is working well now, maybe 105 degrees flex, she still has a lot more

PT to do. However, the hip hurt increasingly as she increased her exercise

activity, and at surgeon's follow up visit yesterday for the knee, she reported

the hip problem, xrays revealed a shortened femur neck compared to original

xrays...obvious even to my untrained eye. Diagnosis is avascular necrosis in

the bone under the sphere covering the femur head, treatment is emergency

revision to a large ball MOM total hip using the same acetabular cup as placed

for the BHR. goes into emergency revision surgery Monday morning, is

quite bummed about it, as she did NOT want a THR. Surgeon's only statement

about the cause of the AVN is that there is increased incidence of it with post

menopausal women with resurfacing, and he now tries to talk post menopausal

women out of getting resurfacing. He did NOT try to talk US out of it, and no

mention of AVN was made at the time we considered our options. We do not feel

we can wait for this revision surgery, as the knee rehab will be compromised if

cannot walk..... :-(

There are many success stories surrounding resurfacing, and we were VERY happy

early on. However, we feel obligated to share this " down " part of our saga

also... and hope and pray gets the life out of the THR the surgeon

tells us we can expect... and there are not further complications and

" unexpected " conditions leading to MORE revisions... avoidance of which was our

strongest reason for choosing the BHR going in.

FWIW,

Barrie &

LBHR Dec 19 2006 Dr Snyder

R Otis Knee Mar 16 2009 Dr Snyder

Revision to L THR & Nephew April 27 2009 Dr Snyder

>

> Joint Replacement/

> > Hi ,

> This is an addendum to Vicky's post about her BHR & longevity. I've had mine

since October of 2006 & have BEATEN THE CRAP OUT OF THEM. I work as a

carpenter/contractor, climb ladders with loads up to 70 Lbs, kneel, squat &

stand, push, pull & carry all sorts of things. The only problems I'm having is

the knees, ankles, & various other supporting joints & bones are having a bit of

a hard time keeping up with working as hard as I like to. I've waterskied,

danced, all sorts of stuff, my 2 year check up the doc said I can do anything I

want to now. I've noticed no problem in the prostheses ever.

> Hope this helps.

> Peace

>

> Bilateral BHR, Hozack, 10/17-31/06

>

[Guest guest]

Hi Barrie,

I am SO sorry to hear that. I hope you will report back to the surface hippy

group? Unfortunately the surgeon that used has had quite a number of

failures. Usually when early collapse/AVN occurs it is due to the surgeon

compromising the blood flow during surgery. I am sure he would never admit

that, but sending her x-rays to a couple of top hip resurfacing surgeons and I

can almost guaranty yout that is what you will find out. Will be getting

a matching S & N stem? Make sure your doctor knows what he is doing with the

revision surgery, he has been known to make a ton of mistakes with resurfacing.

I would see if there is any way you could take to Dr. Su in NYC for the

revision, then you would know she would have a long happy life with the new THR.

He has done quite a few other surgeons badly done resurfacings and revised them

to THR's. Here's the latest.

http://www.surfacehippyinfo.com/Complications/20081207227/Complications/Carl-and\

-Pam/menu-id-84.html

With a happy ending. All the patients I have worked with that ended up getting

revised to large ball MoM THR's are doing great, but I would make sure you go to

a trusted doctor. Please share your story on the SH site, again, so sorry to

hear this.

Vicky

LBHR Dr. Bose Dec 01 05

> >

> > Joint Replacement/

> > > Hi ,

> > This is an addendum to Vicky's post about her BHR & longevity. I've had

mine since October of 2006 & have BEATEN THE CRAP OUT OF THEM. I work as a

carpenter/contractor, climb ladders with loads up to 70 Lbs, kneel, squat &

stand, push, pull & carry all sorts of things. The only problems I'm having is

the knees, ankles, & various other supporting joints & bones are having a bit of

a hard time keeping up with working as hard as I like to. I've waterskied,

danced, all sorts of stuff, my 2 year check up the doc said I can do anything I

want to now. I've noticed no problem in the prostheses ever.

> > Hope this helps.

> > Peace

> >

> > Bilateral BHR, Hozack, 10/17-31/06

> >

>