Belgium Advanced Training Course for Surgeons, June 2008

Advanced Training Course for Surgeons held in Belgium - Overview

By Vicky Marlow

It was very interesting to watch the doctors present from the doctors perspective but it is quite different coming from our side. When we look at it as OUR bodies they are cutting open, it changes the whole view. The following is my view as a patient. — Vicky

This overview of the conference I attended in Belgium, June 25 – 28, 2008 are notes that I took during the presentations and sessions as well as my own personal opinions and thoughts on the subject and some of what I understood while I was there. It is in no way any scientific data and if anyone does see anything that is inaccurate, please feel free to email me and correct me. I can be reached at contact Vicky. To summarize the conference in two sentences, first I will quote Mr. McMinn:

Bad results of Resurfacings are the result of badly done Resurfacing” — Derek McMinn

In conjunction with that, to quote Dr. DeSmet

A WELL DONE resurfacing works well, but is TECHNICALLY DIFFICULT.” — Koen DeSmet

McMinn’s quote was mentioned on several occasions throughout the conference and mainly has to do with the technical difficulty of resurfacing in general. It was clear to me again after attending my third orthopedic conference that the above statement is SO true and was reinforced in several of the sessions during this conference. It appears the many problems that exist today with resurfacings have to do with the surgeon and technique. As with Real Estate the three important factors being location, location, location, with hip resurfacing it is experience, experience, experience.

Now this first part are my thoughts and opinion on the subject, feel free to skip over this portion if you are not interested in my opinion. I will put my opinions in quotations as well as italics so you can skip over these parts if you choose to.

I know many newer patients that post on the board and choose to go to newer surgeons or end up having no choice due to financial matters or insurance limitations get upset by those of us that keep repeating the importance of picking a surgeon with experience. I wish these patients would just understand that many of us take hours out of our every day lives to HELP people. Misguiding someone to a newer inexperienced surgeon is NOT my definition of helping someone. When the question is asked, well then, who will be in a doctor’s first 100? I will tell you who, those that don’t care to take the time to research alternatives. Those like the guy I ran into that was scheduled for a THR and when I told him about resurfacing his response was that his doctor didn’t do them and he trusted his doctor. The gal that posted a week or so ago saying she was having a THR in a few days and wanted to talk to others that had been through it. I emailed her offline and no matter what I told her, she was not going to postpone her surgery that Monday, she was just going to let her surgeon give her a THR. A surgeon that never even told her what resurfacing even was and she was in her 30’s! Well those are the patients that can end up being in a doctor’s first 100, the ones that go into a doctor’s office and just will listen to what they are told and end up with what they get. Like the poor woman many of us met at DeSmet’s brunch in SF. She could barely walk with crutches because the Hemi-prosthesis with a large femoral stem device her doctor had placed inside her, DeSmet flat out told her he would never use a device like that on anyone unless it was a woman in her late 90’s that he knew was going to be wheelchair bound anyway and had very few years left to live. This woman was in her 40’s and was there to get a consult with DeSmet. Last I heard, she is going to go back to the same doctor that did that to her in the first place to fix it, if you can believe that!

As far as I am concerned, those that take the time to seek out information and find their way to the surface hippy message board or this site or email me offline for help, well they deserve to know the truth. Not MY truth but the truth even all of the top surgeons speak. There IS a learning curve with hip resurfacing. HRA is a very different procedure than a THR, completely different.”

Now onto what I learned at the conference and my notes.
Dr. Amstutz - Technique – Crucial

Overall the majority of the problems found in hip resurfacing are surgeon related. Cup malpositioning, femoral component placement off, can cause impingement, neck fractures, femoral neck thinning

Contraindications for hip resurfacing
Age – Some doctors are still using age as a possible contraindication. It appears the more experience a surgeon has, the more open they are to taking cases for older patients, some doctors will look only at a patient’s bone density/quality and not worry about age.

Dr. Amstutz takes much older patients more and more now. He is of the firm belief that eventually hip resurfacing will always be a first choice for any patient unless the condition of the patient warrants otherwise.

Dr. Amstutz began hip resurfacing 35 years ago and in 1987 he started with large diameter heads. He has done some patients that maybe should not get resurfaced but if they request it, he will tell them the risks and possibly still do it.

His view on it is that if surgeons learn how to do it correctly, resurfacing should and will be the primary operation, it is the process of evolution. Amstutz is definitely PRO resurfacing.

Dr. Schmalzried asked the panel their thoughts on THR vs. HRA (Hip Resurfacing Arthroplasty) Dr. Antoniou said you have to listen to the patient and look at the risks involved. Amstutz said each case has to be evaluated individually, you can not look at all females over a certain age, etc. each one is individual.

Life expectancy of resurfacing, Dr. Antoniou said 15 – 20 years
Amstutz has some of his earlier metal poly patients still lasting at 25+ years out. He has been implanting the C+ now for 11 ½ years and thinks there is no reason to believe that hip resurfacing won’t last a patients lifetime.

Acetabular side issues? Some doctors said that if you get inside a patient and find that they have dysplasia which requires a larger cup size, some will at that point bail out and do a THR. Amstutz clearly stated that he has not EVER bailed out with dysplasia cases. Unless a patient is a 4+ dysplasia level then he will tell them they do not qualify but he has done up to 3 level dysplasia.

Summary, some doctors are very selective with their patient selection, some will widen their choice as they get more experience, and some will always be extremely selective.

My own personal opinion - I was extremely impressed with Dr. Schmalzried, we spent a lot of time talking and debating the THR vs. Resurfacing issue. Overall I thought he added a lot to the whole conference and the sessions that he moderated, I felt he brought a nice balance to what could have turned into heated debates, where he was able to bring the panels to some form of agreement in a way that arrived at a conclusion for the surgeons that were there to learn to allow them to take something away from that session and learn from it. Regarding my personal conversations with Dr. S, I definitely agree with him to a certain point, in that certain patients, THR’s will be a better option and solution for them. There are three cases in particular that come to my mind. A friend that I received permission from to post her pictures from her surgery,

I must warn you, photos are extremely graphic images of live surgery.

To show just how bad her bone quality was and how advanced her AVN had become in such a short period of time. Her femur literally fell apart like chalk during her surgery. There was just no way she was going to get a BHR or even a BMHR, a large MoM THR was her only option. She will indeed be very happy with it. Another case is the gal that posted on here a couple of months ago that woke up hysterically when she found out she ended up with a THR because she felt it was the end of her world as she knew it. Another young patient in his early thirties contacted me offline and I emailed his x-rays to three doctors for their evaluations. One top doctor recommended THR’s due to the patient’s anatomy as well as several deformities in both his hips. Another top doc thought maybe a 50/50 chance for resurfacing on one side but a definite THR on the other. His comment was that it does not make sense to give a patient a HRA if it does not restore the patient’s anatomy. The third doctor also a top doctor said he would do his best to preserve the patients bone stock due to his very young age, but since it was such an extremely difficult case, he could not say until he got inside for sure what would be the best for the patient. One thing I have learned out of my past 3+ years of experience posting on this board and speaking to probably close to 1000 patients and many top surgeons is that we as a group have such a passion for hip resurfacing as in many ways we should BUT, we need to keep in mind that it is not a one size fits all solution.

When Martyn was posting a while back he made a point on here that there should be a device for each individual patient, and that device should be the best solution for them. Whether it be an HRA a device similar to a BMHR or a THR. The part that I disagree with when it came to my debate/discussion with Schmalzried is that my belief is similar to Amstutz which is the same as DeSmet, Bose, Su, McMinn, Treacy (I believe it is anyway) that each individual patient should be treated as that, a unique individual and evaluated on what their anatomy, bone quality activity level, etc. is. A doctor should not say all women over 55, immediately turn down and without even looking at the x-rays say a THR would be the better option that I strongly disagree with. So to summarize, I have a whole new level of respect for Dr. Thomas Schmalzried after spending a considerable amount of time speaking with him. I agree with him on many things he says but the one area that we will need to agree to disagree is where that line is drawn as to which patients should be resurfaced and which ones should not. He is an excellent surgeon, I have no doubt about that as well as his dedication to providing his patients with the best possible care and outcome, but if you have a difficult case or are a female over age 55, I would think about going to a different doctor. If you are a female under 55, a healthy active male in his 40’s with a straight case of OA, then by all means Dr. S would make an excellent choice.” Correction here – I received an email from Dr. Schmalzried that states his position is as follows on July 16, 2008

I have resurfaced women in their 60’s and men in their 70’s. Age is not the salient criteria – but a surrogate for bone density and life expectancy on a population basis. Each patient has to be evaluated individually to assess the benefit-to-risk ratio of resurfacing v. THR for them." — Thomas P. Schmalzried, M.D.

On the subject of Learning Curves
The really experienced surgeons all admitted that they are STILL learning today. Amstutz, DeSmet, O’Hara, all have done well over 1000 hip resurfacings and they all agree that the learning curve continues. Amstutz made the comment that NO two femoral heads are the same.

This technology is still in it’s infant stages and they are still perfecting the devices, the instrumentation, the placement of the cups, the angles of the components, the soft tissue preservation methods, the incision sizes, the anesthesia, the rehab protocols. Some mentioned that the newer doctors do have the advantage of learning from doctors that have gone before them to avoid the same mistakes. I agree to some point, but even though they KNOW what causes notching of the femoral neck, why is it that some newer doctors still notch? It is inevitable that the first few times they do something, even though they know to avoid certain things, until they get the hang of it, they WILL make mistakes. Even some of the greats today will still make mistakes now and then, after all, they are only human. But the odds are, the more experience a doctor has, the less mistakes he will make. Again, Dr. Su in his video interview near the end explains the learning curve in stages really well. Go to Dr. Su’s video interview to where the clock says around 3 minutes near the end.

Instrumentation was discussed and it looks like many of the companies are coming out with better and better instrumentation. With some of the designs it makes it nearly impossible for a doctor to notch a neck due to the way the instrumentation is designed to guide the doctor in placement of the pin and find the exact center of the femoral neck.

Approaches were discussed and again there is disagreement among the surgeons as to which approach is better, the conclusion was the approach that works the best for the doctor to get the best results that doctor can get for his patient is the best approach to be used by that doctor. Dr. DeSmet said during his live surgery via video feed that he hated seeing patients of his coming in a year or two post op limping badly with a well placed prosthesis due to having had an anterolateral approach and damage to the gluteus medius muscle.

Neck capsule preservation, during DeSmet’s live surgery he stressed the importance of NOT cutting through the capsule, just release it to save vascularity. Doctors that remove the soft tissue will see more neck notching. It was interesting to see that many of the doctors on the panel DID remove either the entire neck capsule or a large portion of it. Hopefully they will learn after this course the importance of preserving the neck capsule.

Metal Ions
Jury is still out on this subject. Pat Campbell is now independently doing implant retrieval studies. I believe any patient that is diagnosed with metal allergies as the cause of pain or ALVAL should insist that their doctor send their removed device to Pat’s lab for a full study to find out for sure if that was indeed the reason for failure. As I mentioned in a prior post of mine, my concern is that there will be doctors that have poorly placed devices that are causing impingement and higher metal wear and then turning around and blaming it on metal allergies when it could be a reaction to high metal wear due to the malpositioned implant. It is easier to blame it on the patient than it is to accept the idea that the surgeon misplaced the device or notched the neck and the bone under the cap has collapsed as a result and it has nothing to do with metal allergies.

They do have lymphocyte tests now but they are rare to find. Not sure what they will prove. I have personally volunteered myself as a case study since I have extreme metal sensitivity and have had my BHR now for over 2 ½ years, so I am now past the 2 year danger zone for ALVAL to show up.

As far as metal ions on women of child bearing age, both Amstutz and DeSmet agree on the fact that it should not be an issue for women of child bearing age where many doctors will not implant MoM resurfacings. The question is, are poly debris really any better for an unborn fetus?

Amstutz has had no evidence and has had patients with high levels of metal sensitivity with no problems showing up at all.

Very important issue to keep in mind that there are TWO parts to the metal ions discussion.

Wear related problem (Metallosis) is very different than metal sensitivity. (Hypersensitivity, Inflammatory lymphocytes)

They have found that activity has NO correlation to metal ions.

Problems with HRA

• Impingement
• Socket problems

The following was a slide regarding the conclusions drawn on metal ions.

Conclusions

• Significant differences between current generation resurfacing devices
• Those differences are less important compared to the extreme high levels due to malpositioning of components
• Some patients have elevated ion levels preoperatively for unknown reason
• No correlation between ion levels and activity
• Correct positioning of components is crucial
• Acetabuler Malposition Early problems – dislocation, Later problems Impingement

Lessons to be learned

1. Component misalignment leads to increased – even dramatic – wear
2. Not a gradual but a step increase
3. Positioning of implants (inclination, anteversion, relative positioning)
4. Very early failures: head
5. Later failures: cup (wear)

Bursae
Painful Resurfacing - Dr. Schmalzried lead this panel discussion and started it off by saying, folks this looks like we have very bad news here. From what he heard during the discussions, the biggest problem with resurfacings was a surgeon problem. It was all technical in nature. So again, back to McMinn’s quote and back to what I and many others on the board like Alan Ray and Chris Saunders say over and over again, EXPERIENCE. The more experienced a surgeon is the better your chances of a successful resurfacing that will last you a lifetime with no problems of impingement or long term pain issues like ongoing groin pain, etc.

Devices
There are a lot of different devices out there, each has its pluses and minuses. Apparently the Conserve Plus, the Durom and the ASR device have stems proportionate to the device size. With the BHR the stem is the same exact size no matter what size the component is. The smaller the femoral neck the smaller the stem needs to be for proper stress shielding. With a component size smaller than a 42 which is what I have, a BHR should not be used. So a 40 or a 38 should always be used with one of the other devices due to the stem size of the BHR. From what I understand the C+ device has not been available in India therefore Dr. Bose uses the ASR in these cases. Dr. DeSmet chooses to use various different devices. He believes the best resurfacing devices out there right now are the BHR and the C+. You will see his explanation in his latest video interview that I did with him in Belgium. It  The Wright C+ with it’s A class material that has recently been patented appears to have the lowest metal wear of all the implants available out there. Please watch Dr. Amstutz video interview for more information about the C+ device. The stem also is smaller than the BHR stem and therefore it will work better in smaller boned patients. Or patients that have a narrower femoral neck sizes.

DeSmet’s live surgery
He keeps the patients blood pressure usually around 60 – 65. There are so many steps he takes to make sure the patient gains the correct anatomy. Measuring, re-measuring, angles, depths, placement, amounts removed to maintain equal leg lengths, neutral position of guide pin. Heterotopic ossification prevention, placing protective cloth to protect the tissue from bone fragments, believe it or not, not all doctors do that, just watch some of the live video surgeries available online for viewing and you will see the difference between sloppy and exceptional work. Removing osteophytes, if you do not remove them, the patient will impinge. So some of you patients complaining of pain might have had osteophytes that the doctor left in you. Again, the importance of picking an experienced surgeon for this. DeSmet has revised around 63-65 malpositioned resurfacings done by other doctors. Dr. DeSmet now uses a smaller incision than he used to, about half the size he did before.

Rehab
Dr. DeSmet came across pool therapy quite by accident. He found that his patients were going into the pool at the Holiday Inn with a special waterproof STERILE bandage and they were recovering at a much quicker pace than ever before. This is the reason for him adopting this in his post op rehab protocol now and for Hugo starting the Villa for aqua therapy sessions beginning day two post op for all patients.

Dr. Kim in Ottawa does not encourage running or high impact for any of his patients.

Amstutz believes a patient can do anything with their implant, it will just have a shorter life of the implant the same way you would wear a normal hip with higher impact, you will also wear a metal hip or the bone around it.

The following were taken off of slides that were presented that I took a picture of:
Anesthesiologist
Blood transfusion
2004    5.9%
2005    5.1% control hypertension
2006    2.5% Cell saver
2007    1.0% Tranexamic acid

MM Resurfacing
Conserve Plus
Technique changes
3rd Generation (current technique n=329)

• Intertrochanteric suction (since 1/04)
• Carbojet (since 4/04)
• Thin shells (since 10/03)
• Larger chamfer (“Europeanc” remaing -170°)
• Cementing stem for large (>1cm) cysts only and small component size <48mm.
• 197 stems cemented (59.9%)

Continuing with the discussion...

Uncemented
Amstutz worries about the coating on the stem of the Cormet device still cause head stress shielding, one of the panel members brought up that wouldn’t you say the same about your method of cementing the stem? He said he does not see it as the same, that he sees cementing the stem as just part of being a filler. He did a series of a blind study of 400 controlled group half stems cemented half uncemented and so far no difference between the two. Not one failure yet in a cemented stem some going on 8 years. Now he just only cements the stem on patients he would otherwise do a THR on.

On cementless he says there has to be a perfect fit between the bone and the component. The consensus on cemented is that it is fine. The foundation of bone needs to be good enough for cementless. There was a whole discussion on cement mantle thickness that went into a lot of detail. You can see the slides in the photos section under conferences.

To summarize the whole conference, again, I will quote Derek McMinn and Koen DeSmet

Bad results of Resurfacings are the result of bad Resurfacing” — Derek McMinn

A WELL DONE resurfacing works well, but is TECHNICALLY DIFFICULT.” — Koen DeSmet

Go to an experienced surgeon that has no problem continuing their education on technique and will continue to learn from other doctors by attending these conferences and sharing what they have learned.

Ask your doctor about experience and continued education on hip resurfacing. A LOT of new advances have come about and unless the doctors are coming to these courses and learning them, there is no way they could possibly know. Send them to this link and tell them they need to sign up for this online. There was a ton of info presented at this conference and it is all available to them now.

Click to visit the Advanced Course Resurfacing website.

And…that sums up this patient’s perspective.

Vicky Marlow