Dr. Rubinstein Interview, Chicago, IL

1.)  Hi Dr. Rubinstein, can you please first start out by telling us how you got started with Hip Resurfacing and give us a little background on your experience as a surgeon.  Where did you train for hip resurfacing?  Who trained you?  Did you continue your training after starting resurfacing?

I have been a practicing orthopaedic surgeon since 1991. I finished my residency at the Medical College of Wisconsin in 1989. Following that I did an Adult Reconstructive and joint replacement fellowship in Edinburgh Scotland and a hand fellowship in Grand Rapids Michigan. Since then I have been practicing general orthopaedics with a sub interest in joint replacement. I first became interested in hip resurfacing when the first of the new generation hemi implants came on the market in the late 90s. I had a number of young patients with avascular necrosis with good actable bone. This was before alternative bearings (metal-metal or ceramic-ceramic) were widely available and conventional THR did poorly in this population. I did about 15 patients with the original Wright conserve implant on the femoral side only and all but one are still doing well. The one failure was due to actable cartilage erosion and was revised to a metal-metal THR after 8 years. When the actabular components first were available I spent a day with Dr Gross in South Carolina learning from him. I assisted and observed 4 Biomet Recap cases there. I also spent a day with Dr. Stachniew in Galesburg Illinois and learned the Wright C+ system. I did a few of each prior to the BHR system becoming available in the USA. I then took a trip to Birmingham Englans and spent a few days with Mr Derrick McMinn the BHR design surgeon. Since then I have settled on the BHR implant and have done over 100 resurfacings as of the end of 2008. During that time I have kept up with the latest developments by attending a few conferences and keeping up with the published articles on resurfacing.
 

2.)   Do you do the neck capsule preservation technique in your surgeries?
I always preserve enough capsule to maintain the blood supply to the bone but not so much that it gets in the way of doing the procedure.

3.)  Which approach do you prefer to use anterolateral or posterior? I use posterior approach.  I have not had any problems with this.

4.)  What is your opinion on the Direct Anterior approach for hip resurfacing, not the antero-lateral approach where the incision is on the side but the Direct Anterior approach?
I have no personal experience with it as of yet.  While I have read about it I have not yet seen one done.  I would like to try one at the next cadaver lab that I am at.  Then I could form a truly informed opinion on the approach.  The concept does seem interesting though.  

5.)   How long do you feel it takes for the bone to be fully healed, actually grow into the prosthesis?
I feel that bone integrates into the acatabular component in 6 weeks but takes about 4-6 months to fully mature.  In the cemented femoral component I use there is no bone growing into the prosthesis but the femoral bone needs to remodel to the new stress patterns applied to it by the implant.  That takes 4-6 months.
 

6.)  Barring any complications, how many days in the hospital will a patient normally stay?
Hospital stay is extremely variable and to a large degree depends on the patient.  Many are out in 2-4 days but there are some that need to spend more time on the rehab unit and may be in  7-10 days before going home.

7.)   What is your typical recovery time after resurfacing, what is your typical rehab protocol?  90 degree restriction? Walker” Crutches Cane? amount of time?  Blood thinners?  TED stockings?  Ice?  PT Again there is lots of variability on recovery times.  Most of my patients are walking without support or with only a cane when they see me for a 6 week check.  Most have also gotten rid of most of their limp by that time.  My rehab protocol is progress based.  The first steps are to work on regaining lost motion and strength along with restoring normal gait.  This is done with physical therapy starting at home followed by out patient therapy.  I maintain a 90 degree flexion maximum for 6 weeks to allow scar tissue to stabilize the hip.   Most patients tart out with either crutches or a walker depending on which is safer and easier for them.  Patients progress to a cane and then no support depending on their progress and what they need for safety and stability.  I use a blood thinner for a total of 4 weeks.  TED stockings are used until the patient is walking and moving about well.

8.)  How long before a typical patient is allowed to drive a car, return to work? Return to work is most dependent on what type of job the patient has.  Sit down jobs are easier to return to but frequently transportation is an issue.  Returning to driving has no set time frame.  It is dependent on when a patient can safely operate a car and whne they are off narcotic pain meds.  Typically patients can drive in 2-3 weeks for a left hip and a little longer for a right since that leg needs to operate the pedals.

9.)  What is the recommended time you tell your patients before they can start to run again/do impact sports?  Are there any sports you don’t want your patients to participate in after surgery?  Out of the patients you have resurfaced what are some of the sports they have returned to?  
I like patients to wait 6 months for impact sports to allow the bone time to remodel following the procedure.  Starting to soon risks a  stress fracture in the femoral neck.  Once the bone is fully healed I allow full activity without restrictions.  I have had patients return to running, cycling, skating, skiing, swimming, baseball, basketball and ice hockey.  To see a video of me playing hockey with one of my resurfacing patients go to the following link.  Tom Dolan's story It was filmed by another of my resurfacing patients who you can see walking limp free in the stands.

10.)  What is your take on cementless (femoral) devices for resurfacing?  
While I feel that it is important for cementless femoral components to be tried I don’t feel there is yet enough data to allow it to be used widely.  I suspect when all the long term data is in (20-30 years from now) there will be little difference in the results of the cemented, vs. the uncemented femoral components.  With the excellent 10 year data on the cemented femoral components I see little reason for me to use uncemented components.  That said I do feel that Dr. Gross’s work with the uncemented components is important and I will follow his results with interest.

11.)     Do you have a cut off age for resurfacing patients or do you go on a case by case basis?
I have no specific cut off age for resurfacing and go on a case by case basis.  There are some age restrictions that have been put on by some of the insurance companies though, so patients need to research the policies of their individual insurance carriers.  I know some had a 55 year cut off.

12.)  What type of anesthesia do you use general or epidural or ?  
I find that from a surgeon’s point of view either one works well and allows the procedure to be done well with no difference from my point of view.  There are sometimes medical conditions that will dicatate one over the other.  If not then it boils down to patient preference.  Typically the patient and the anesthesiologist will meet prior to the procedure and decide.

13.)     Are there any cases that you will not take in particular, AVN, dysplasia, small cysts.  Maybe touch on some of the very difficult cases you have been able to resurface.
I don’t have any cases in particular I will not take but might refer on an extremely difficult dysplasia to one of the resurfacing super specialists.  AVN is common in my practice and usually not a problem because most of the time the avascular bone is in the part of the hip that is milled away in the shaping of the femoral head.  The same can be said for cysts.  In the rare case where the cysts or avascular area are too large then a big head metal-metal THA would be used.  I always try to mill the bone first and see if a resurfacing is possible.  Thus far I have never had to abandon a resurfacing for this reason except on two cases where I was pretty sure resurfacing was not going to be possible based on the pre op x-rays.

14.)    Do you do bilateral surgeries same day, if not how far apart do you recommend? 
I have done two bilaterals on the same day with good results.  The recovery is kind of tough though and it is not for everyone.  Patients need to be in excellent medical condition to do same day bilaterals.  If not doing the same day then spacing is based on recovery progress.  Most patients could be ready in 2-3 weeks if they want.
 

15.)     What device do you prefer to use for hip resurfacing?
I am currently using the BHR.  I have also tried the Wright C+ and the Biomet recap.  They worked well but I have sleected the BHR because they have the longest data and it is very good, giving me no reason to change implants.  As more data becomes available over time I would change if one of the other implants shows superior results.  I suspect thought that they will all be about the same when all is said and one.

16.)  If you can’t perform a hip resurfacing – what THR device do you prefer and why?
If I find I can’t do a resurfacing while in the middle of the procedure due to bone quality issues I will substitute a Smith and Nephew big head metal-metal THR which I always have available as a backup in the room.  If the x-rays pre op show a resurfacing is not possible due to anatomy then I will use either a Depuy or a Biomet big head metal-metal THR.

17.)   What do you consider an adequate number of surgeries for a doctor to be proficient at hip resurfacing?  
I think most good hip surgeons will be reasonably proficient after 20 resurfacing but I think that most surgeons will continue to make incremental improvements always no matter how many they have done.  I always strive for a perfect case every time.