Hip Surgery With a Future

Ruby Washington/The New York Times
Dr. William B. Macaulay Jr. is one of this country’s leading practitioners of hip resurfacing. Since it is not any easier on a patient than a total replacement, he says a patient should have pain every day before even thinking about it. 

But woe to those who outlive their artificial hips, which typically cannot be counted on to last more than 20 years or so.

Because it is difficult to extract and replace a worn-out or defective artificial hip, doctors routinely advise patients to put off hip replacement as long as possible. For middle-aged or younger people whose hips have been damaged by disease or injury, that typically means a punishing waiting game.

Now, though, an alternative to total hip replacement can offer an interim solution to many younger patients.
The alternative, called hip resurfacing, usually yields at least as many short-term benefits as a total replacement. It costs about the same and is typically covered by insurance.

And though many patients can expect to outlive the treatment’s effectiveness, hip resurfacing has the advantage of preserving enough healthy bone to allow for a future total hip implant.

“It’s nice to know that down the road, if necessary, it will be an original total hip — not a revision,” said Keith McDonald, a 54-year-old air traffic controller from Melville, N.Y., whose right hip was resurfaced late last month. This past Tuesday, just 15 days after the operation — and at least a week earlier than doctors would recommend — Mr. McDonald drove his car. “Every day I do more,” he said.

Tens of thousands of patients around the world have had hips resurfaced in the past decade. That includes some Americans who went overseas before the Food and Drug Administration started allowing it to be done in this country last May.

“The demand from patients and surgeons is tremendous,” said Brian Austin, of Smith & Nephew, the British maker of the F.D.A.-approved resurfacing system.

More than 400 surgeons in the United States have now been trained to use Smith & Nephew’s product, which is known as the Birmingham Hip System. Competing devices already sold overseas are expected to begin arriving in this country later this year.

For all its potential advantages, hip resurfacing surgery is actually no easier for the patient or doctor than hip replacement. And the recuperation may not be any quicker. While many activities can be resumed within weeks, complete healing can take six months or longer.

And a number of medical and health conditions, like kidney disease and obesity, may make even young patients poor candidates for resurfacing.

There are enough potential drawbacks, in fact, that doctors offering hip resurfacing say — as they do with standard hip replacements — that the procedure should be deferred as long as possible. That typically means waiting as long as the patient can tolerate the pain from the arthritis, bone damage or other conditions afflicting the hip.
“You should have pain every day before you even think about it,” said Dr. William B. Macaulay Jr., a Manhattan surgeon who is one of this country’s leading practitioners of hip resurfacing. “If you are doing it in people with moderate pain who just want to improve their tennis game, that’s crazy.”

Experts say that 10 percent to 15 percent of hip-replacement candidates may find hip resurfacing a viable alternative. But unless they are Web-savvy like Mr. McDonald, who learned about it only through his own Internet research, they may not have heard about the procedure.

Patient-support Web sites like Surfacehippy often post complaints from patients saying that surgeons not trained in resurfacing tend not to tell their patients about it.

“I’ve been a volunteer paramedic with the Melville Fire Department since 1971, so I’m interested in medicine and not reluctant to do research on the Web,” said Mr. McDonald, recalling how he had discovered resurfacing and found Dr. Macaulay, the surgeon who operated on him.

Vincent Torretta, a second patient who underwent hip resurfacing with Dr. Macaulay the same day as Mr. McDonald, also discovered the procedure through his own Web research. Mr. Torretta, 60, a loan data analyst with Bank of New York, lives halfway up a mountainside near the Pennsylvania border in Glen Spey, N.Y. He sought relief when chronic pain in his left hip and knee left him unable to pursue outdoor activities.

He found that Dr. Macaulay, the director of the Center for Hip and Knee Replacement at NewYork-Presbyterian/Columbia hospital, was the nearest expert in resurfacing.

“It sounded like it would allow me to lead a more active life,” Mr. Torretta said.

He said his insurer, United Healthcare, initially denied coverage because he wanted to go out of the approved doctors’ network and that several of the United representatives whom he spoke with on the phone were confused because they had never heard of the procedure. United eventually provided oral approval. Mr. Torretta still did not have that in writing by the time he underwent the operation.

Publicity about the procedure may soon pick up. Stryker, a big American maker of artificial joints, is expected to begin marketing a similar British-designed device by early fall. Another device maker, Wright Medical, is close on its heels.
Other big orthopedics companies like Zimmer Holdings, Biomet and the DePuy Orthopaedics division of Johnson & Johnson that are selling resurfacing systems overseas are further from getting approval in this country.

Competition could eventually bring down prices. Smith & Nephew currently has a list price of $12,500 for the Birmingham system, and the complete procedure often costs more than $25,000, which is comparable to a total hip replacement.

At least shorter term, though, competition is constrained by the limited number of doctors who can offer resurfacing and the even smaller pool of practitioners like Dr. Macaulay who gained experience by participating in clinical trials and training courses overseas even before the F.D.A. approved the Birmingham hip.

Many patients, as a result, are continuing to go outside the country. Some fly to India, where the procedure is available for $8,000. Others pay $15,000 or so in countries like Belgium or Britain, which have surgeons who have done hundreds or even thousands of resurfacings. But insurers rarely cover such “medical tourism,” as it is known.
Both resurfacing and total hip replacements involve implanting a metal cup in a pelvic socket called the acetabulum. The primary difference is how each procedure deals with the top portion of the femur, the long bone in the thigh that fits into the socket.

In resurfacing, the head of the femur is shaved to a rounded shape and then covered with a metal cap. The cap is anchored by a spike cemented into a small hole the surgeon drills into the center of the bone.

In total hip replacement, the entire head of the femur is sawed off and replaced by a large hemispherical device anchored by a far longer spike driven deeper into the femur. It is this major alteration of the femur that often leaves too little solid bone to make a follow-up replacement procedure feasible.

But hip resurfacing is by no means minor surgery. It requires a more precise fit between the cap and cup, and the intact head of the thigh bone leaves the surgeon less maneuvering room. As a result, resurfacing requires a larger incision than total hip replacement.

The operation may take slightly longer than the three to four hours of standard hip replacement. And patients lose twice as much blood, although transfusions are rarely needed, according to Dr. Macaulay.

There are stories of patients rapidly returning to work and even rigorous athletic competition, like Cory Faulk, a triathlete who ran a marathon last year within three months of getting a Birmingham resurfacing. But doctors say the average patient may recover no faster than a patient who gets an implanted total hip.

Nor is it yet clear whether range of motion after recovery is significantly better with resurfacing, although many patients like Mr. McDonald and Mr. Torretta say they are expecting that to be the case, based on the many success stories they have encountered. Indeed, Mr. McDonald said his expectation of greater mobility, including the ability to squat easily when working as a paramedic, was his main reason for choosing resurfacing.

Mr. McDonald began suffering disabling pain in his right leg and back last summer after his chair at work broke when he leaned back too far. The ultimate diagnosis was that the top of his femur was dying because its blood supply had been cut off.

Mr. Torretta, meanwhile, had a far more common problem — degradation of the joint from arthritis that probably stemmed from a lifetime of running, football and other outdoor activities.

Dr. Macaulay warned both patients that he could not be sure their bones would support resurfacing until the surgery began and that he might have to switch to a total hip replacement.

Both men now face a number of risks common to all hip procedures, including infections or fractures.

They have also been warned that in about 1.5 percent of resurfacing cases, a fracture occurs in the femoral neck — a thinner portion of the bone below the head. The problem, which is rare in total hip replacements, can sometimes be treated by implanting pins but usually requires a procedure akin to total replacement.

There is also uncertainty about the potential health impact of metal ions scraped off as the cup rubs against the cap. None of the patients in clinical studies displayed problems from such ions, whose electrical charge makes them highly reactive. But lab studies have raised fears they could cause cancer.

As a precaution, the F.D.A. has said the device should not be implanted in several classes of patients, including women who plan to have children and patients whose kidneys have been weakened by diseases like diabetes.
Some doctors say that resurfacing in the hands of experienced surgeons might result in repaired joints that last longer than most total hip replacements. But other experts, like Dr. Justin G. Lamont, the chief of orthopedic surgery at Ticsch Hospital of New York University Medical Center’, say the devices approved for the American market are too new to be certain.

“Until we get 20 years out,” he said, “we are not going to know how well resurfacing holds up.”

For full article:  Hip Surgery With a Future