Total Hips Versus Surface Replacement: The Fight Of The Decade

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Guest Blog: Today's blog post was written by Richard H. Rothman, MD, PhD. Dr. Rothman is the founder of the Rothman Institute and the James Edwards Professor of the Department of Orthopaedic Surgery at Jefferson Medical College, Thomas Jefferson University. He is an orthopaedic pioneer, with an international reputation in joint replacement procedures. The topic is an important one: the differences between total hip replacement and hip resurfacing. Dr. Rothman and I welcome your comments.

Total hip replacement or arthroplasty (THA) has proven itself to be the single greatest surgical contribution to mankind during the past 30 years. It is extraordinarily safe, effective, and durable, and these characteristics have been proven by a variety of surgeons in every major continent of the world. The evidence is incontrovertible. In the past three years there has been a resurgence of interest in an alternative operation termed "Surface Replacement Arthroplasty" (SRA). These proponents suggest several theoretical advantages which have yet to be proven with careful scientific study. In this essay, I will try to illustrate this debate through a boxing match of ten rounds summarizing the evidence as to which operation will triumph.

The first, and probably the most important round relates to the short term survivorship of the operation. If the success rate during the first five years is not superior for SRA than all of the theoretical advantages are meaningless since the procedure will be plagued by short term failure. Amongst the worst data indicate a 34% failure rate at two years with the very best statistics indicating a 1% failure at 3 or 4 years by the designers and strongest advocates of SRA. At best, surface replacement is a tie with total hip replacement but when one looks at the overall experience for all types of patients, the early failures are much greater for surface replacement. Ultimately we need large surgical series by non-designers without financial conflict, performed in multiple centers around the world. The leading cause of failures in the short term is fractures of the femoral neck reported in Australia to be 1.5%.

Round two relates to the difficulty of the procedure since complex operations have greater exposure to technical complications than surgical mistakes. There is a uniformed consensus that surface replacement is complicated and total hip replacement is simple and reproducible. Although there is an argument that surface replacement preserves bone, in fact re-operation on SRA is more complex than the usual revision of a THA.

A third round in this boxing match relates to the stability of the hip and the ability to withstand dislocation. There is no evidence at the present time that moving to SRA lowers the dislocation rate and certainly it is impossible to adjust leg length discrepancy and restore the proper hip offset.

The fourth round relates to range of motion of the hip. Careful biomechanical analysis indicates a greater range of motion for THA, analyzing the pertinent data, particularly the head/neck ratios.

Round five of this fight centers on restoring a "natural feel" with the procedure, the thought being that resurfacing has a more natural feel. In point of fact, most total hip replacements result in a hip that patients perceive as totally normal.

Round six relates to an issue that is very important to young, active patients and that is the level of function allowed after surgery, including skiing, tennis, and jogging. With today's total hip replacement, patients can return to all of these activities with the same level of confidence that is provided by SRA. The surgical recommendations are frequently based more on a surgeon's judgment and not objective data.

The seventh round is important and the outcome is not certain. It relates to the metal on metal bearings used with surface replacement. There is no question that an increased load of chrome and cobalt ions are delivered to patients with metal on metal bearings and SRA. While not proven, there are major concerns with regard to immune reactions and allergies, developmental toxicity, renal toxicity, and carcinogenesis.

The eighth round focuses attention on the selection of patients. Almost all patients are eligible for total hip arthroplasty while there are many exclusions now recognized for selecting patients for SRA. The exclusion of patients for SRA include deficient bone stock, advanced age over 65, female sex, AVN, and rheumatoid arthritis.

As the boxing match draws near the end, round nine focuses on cost. Of course, patients would like to say price is not an object...as long as they do not have to pay. However, in today's health system, there is not enough money to give everyone what they need or want, and the cost of SRA in most centers exceeds that of total hip replacement.

The final round is the long term survivorship and success as defined by re- operation. There are a multitude of series around the world where the success rate at 10 years after total hip replacement exceeds 99%. There is little data regarding 10 year survivorships as success rates for SRA. The data that is available indicates success rates at 10 years ranging from 34% to 79% - far inferior to total hip replacement. The long term success of today's contemporary models of SRA is yet to be proven...only time will tell.

In summary, the score by round indicate that total hip arthroplasty won five rounds, tied four rounds with the 10th round yet to be certain. The total score shows a triumph for total hips with five wins, four draws, and one question mark. Clearly THA is a "knock out" operation. Most scientists who are students of total hip replacement agree that the long term success of SRA remains to be proven. In the interim, a prudent patient will select total hip arthroplasty.

Related Topics:

• WebMD Video: Hip Replacement
• Questions and Answers about Hip Replacement

Read This Before You Get Put to Sleep :)

A Book Review: An Unspoken Part of Surgery

I was presented with an advance copy of a book I do not think I would purchase as a patient. It was also a book that had information I absolutely needed - as a patient. That's a tough situation. I need all this information but the book has too much information.

Panchali Dhar, MD is a well-respected anesthesiologist at New York Hospital, one of the premier medical institutions in this country. She has written a book entitled: "Before the Scalpel: What everyone should know about anesthesia." It is not really what everyone should know - it sort of is what everyone could know if they read this superbly written book.

The book is beautifully written, in a simple yet elegant style presenting extremely difficult concepts in an easy to understand format. There is not a nurse, medical student, surgical resident, or medical lawyer who should not pick up a copy of this book. Medical and nursing students get little to no formal training in anesthesiology although an anesthesiologist is present at nearly every operation that occurs in this country. This book has the information even they can use.

Dr. Dhar details everything from the machinery in the operating room, to explaining that many types of anesthesia, to complications, and more. It is nearly two hundred pages long and every sentence, every concept is crisp and concise and valuable to anyone who plans an operating room experience.

So you are John or Jane Q. Public. What in it for you? While the information is all there it is probably too much information for the average patient. The focus of apatient is on the specifics of their own anesthesia and surgery and not a treatise on the whole field. You would need to be extraordinarily interested in medicine as a lay person to read this cover to cover. Don't get me wrong, if you did read the book it would lower your pre-surgical anxiety but it may not go further than that.

There is a place for this with patients, though. All surgeons should make this book available to their patients to read and then return it to the surgeon after the surgery to go to the next patient. Too often patients get to the operating room and meet the anesthesiologist minutes before the procedure. Dr. Dhar's book won't prevent that but is a great starting point for a patient to learn more about this critical part of the surgical team.

I recommended to the author that she produce a mini-pocket book for patients that condenses the power of this book in a patient focused format. It would be a great compendium to this text.

Dr. Dhar should be commended for this excellent contribution to the medical literature for professionals and the public.

Dr. K.

Disclaimer: I never met Dr. Dhar, nor have I ever spoken to her. My sister, who is a master Pilates instructor in New York City happens to teach and train Dr. Dhar in Pilates and told Dr. Dhar that I am a surgeon. She was kind enough to send me an advance copy of the book. I am not involved financially in this book in any way. Too bad, though. It think it will be a good seller.

Related Topics:

• Sizing Up Surgery
• Questions to Ask Before Surgery

Ask Your Doctor... Ask Your Doctor WHAT???

A day does not go by where I do not see a television advertisement for a prescription medication. The final tag line is: "Ask your doctor about THIS NEW DRUG."

I am trying to figure out what exactly patients are supposed to ask me. In arthritis and pain management, the following drug categories and devices have had this tag line:

• Anti-inflammatory injections for rheumatoid arthritis
• Partial knee replacements
• Knee replacement supposedly (but not really) designed for women

Does anyone out there have any idea what to ask their doctor? I believe what the companies want to happen is the following:

"Hello Doctor, I want to ask you about Drug X. Why don't you use it? Why didn't you tell me about it? According to the television, it is the perfect drug for me. I am now asking you about it to put pressure on you to prescribe it - irrespective of whether it helps me... and by the way, the television is a better source of information than you."

Drug advertisements for arthritis and pain medications have their place. But there really IS no substitute for a doctor.

Doctor K.

Related Topics:

• 10 Questions to Ask Your Doctor About Arthritis Pain Medicine
• Pain Management: Doctors Who Treat Pain

Bad Surgeons, Bad Communication, or Just Bad Disease?

I cannot tell you how many message board and blog posts I have read over the past years concerning treatment that sounds as though it would only be offered in medieval times. I am not sure whether this is because the patients posting do not understand what is offered to them or they simply are going to the wrong doctors. It may also be a case of such bad disease that there may not be a reasonable surgical solution.

Here is the challenge for now:

If you feel you have been a victim of some type of flawed orthopedic surgery or decision-making in your case, post it here. Lay it on. I will then take all these posts, review them with a group of colleagues, and see if we can make heads or tails of them.

Dr. K.

(If you think you will post something to get ammunition for a lawsuit - forget it. We will analyze the posts to give positive, general information for everyone to learn from.)

Related Topics:

• WebMD Video: Stopping Post Operative Orthopedic Pain
• WebMD Video: Knee Replacement With More Flexibility

Technorati Tags: orthopedic surgery, joint replacement, health and wellness

Advances in Knee Replacement: Partial Knee Replacements

I recently returned from observing at a course given by a device manufacturer concerning partial knee replacements. The course is given because the FDA mandates that for the company to sell the replacement to a surgeon the surgeon has to take this course. It is a 16-hour course. It does not qualify you to put in the replacement. It does not give you any skill you did not have before. It exists because of FDA rules concerning new products and their safety.

I bring this up because I saw this on a web site of an Orthopaedic Surgeon: "Dr. X is the only surgeon FDA-certified to put in the XXXXX partial knee replacement."

This, of course, is not true. It actually could be an offense punishable by the Office of Professional Medical Conduct because the FDA does not certify surgeons to put in replacements. They can only certify the sale or distribution of the implant.

What certifies a surgeon to put in a partial knee replacement? Last year I personally implanted over 125 partial knee replacements. According to the sales department of the device company whose implants I choose, this puts me at approximately number four in the nation for this particular implant. In fact, the number of partial knee replacements I personally implanted surpassed the combined number of the four largest medical centers in NY. Maybe, maybe not.

As previously noted here in this blog, surgical quality does have a connection to surgical volume. It is not direct and it is not absolute, but there is a connection. Of all the joint replacement procedures that have gained popularity in the last 25 years, a partial knee replacement demands a high level of surgical skill and experience. When I operate at a regional medical center and teach residents (surgeons in training) I commonly inform them that "the hands can only do what the mind knows." In other words, it is what you don't know that can hurt you.

Partial knee replacements have many advantages in the right patient. The recovery is faster and the results, from a patient satisfaction point of view, are consistently better than total knee replacements. It is crtical, though that the surgeon has the experience in doing the surgery. Do not be afraid to ask the following questions:

1. When did you perform your first partial knee replacement?
2. How many have you performed in the past month?
3. Can you show me documentation that the number you said you performed is accurate?
4. How many have you performed in the last year?
5. Can you show me documentation that the number you said you performed is accurate?
6. What is the most common knee procedure that you do?
7. Can you show me documentation that the number you said you performed is accurate?

Don't be afraid to ask the obvious.

Dr. K.

Related Topics:

• Knee Pain Overview
• 4 Fixes for Knee Pain

Technorati Tags: partial knee replacements, unicompartmental knee replacements, knee resurfacing