Resurfacing FAQs

• How many resurfacings have you done?
• Where did you train?
• How many complications have you had?
• How many times during surgery have you had to change to a THR instead of a resurfacing and why was the change made?
• For what reasons would you switch from resurfacing to a THR after starting the surgery? If you switch, what device would you be using for a THR?
• What hip resurfacing device (prosthesis) do you use, how long have you been using it and why do you prefer it?
• Do you use cemented or uncemented? Why?
• Do you cement the stem?
• Will you be preserving my hip capsule?
• What anesthetic do you use?
• How long does the surgery take?
• What surgical approach do you use? Anterior or Posterior?
• What is the incision length?
• What are the specific risks of hip resurfacing compared to standard hip replacement using a ceramic on plastic bearing?
• What is your post-op protocol?
• What hospital do you use?
• What is their infection rate?
• Have any of your patients had infections that required IV antibiotics following resurfacing?
• How long will I be in hospital?
• When will I be 100% weight bearing?
• When can I return to sport?
• Are there limitations after hip resurfacing?
• What surgical approach do you use? Anterior or Posterior?
• What is the incision length?
• What are the specific risks of hip resurfacing compared to standard hip replacement using a ceramic on plastic bearing?
• What is your post-op protocol?
• What hospital do you use?
• What is their infection rate?
• Have any of your patients had infections that required IV antibiotics following resurfacing?

How many resurfacings have you done? (not observed or assisted with or including hemi-resurfacings)

I have done more than 600 metal on metal hip resurfacings/replacements since 2006.

Where did you train?

I got certified to do Birmingham Hip Resurfacing after completing the BHR training course in Charlotte, NC in December 2006. After a trip to Dr. DeSmet in Gent, Belgium, I started to do hip resurfacings in February 2007. I have also visited a number of hip resurfacing surgeons, including Derek McMinn, over the years to improve my technique. I have lectured on hip resurfacing and have trained surgeons in this technique.

How many complications have you had?

The second patient I performed a hip resurfacing on had less than 90 degrees of hip flexion and complained of pain with physical activities. I believe this was the result of a large CAM legion and an anterior rim osteophyte that I did not remove at the time of surgery. I performed an arthroscopy to clean out the osteophytes 9 months after surgery and the patient has had improved range of motion and no longer complains of pain.

I have also had to revise a cup that was not seated deep enough and five female patients with reactions to the metal on metal bearing. I have stopped doing hip resurfacings in women in 2010 since I believe the revision rate is increased (smaller component size, edge loading?)

How many times during surgery have you had to change to a THR instead of a resurfacing and why was the change made?

Once in a patient with severe AVN. He was 28 and had been on systemic steroids for most of his life. During the surgery I was uncomfortable with the amount of necrosis (>50%) as well as the quality of the remaining healthy bone and decided against hip resurfacing.

For what reasons would you switch from resurfacing to a THR after starting the surgery? If you switch, what device would you be using for a THR?

In general we know preoperatively if a patient is a candidate for hip resurfacing. Factors like age, gender, activity level as well as bone quality and bone shape on the preoperative x-ray help me decide if a patient is a candidate. Occasionally one might encounter weaker bone than expected or face significant bone necrosis in patients with avascular necrosis. If I am at all worried that I might not be able to do the resurfacing I usually discuss this prior to surgery to include the patient in the decision process.

If a hip resurfacing is not possible I will use a ceramic on plastic standard total hip replacement.

What hip resurfacing device (prosthesis) do you use, how long have you been using it and why do you prefer it?

I have been using the FDA approved Birmingham Hip Resurfacing (BHR) by Smith and Nephew. I prefer the BHR because of its FDA clearance, its proven track record and number of publications that have confirmed its excellent long term outcome. I have now 8 years of experience with this device and am happy with its outcome.

Do you use cemented or uncemented? Why?

I use cemented femoral component fixation (resurfacing on the femur) and uncemented press fit fixation for the acetabular component. The excellent long term results of cemented femoral components published in the literature and my own experience suggest that there is no benefit in switching to uncemented fixation. Until the literature provides convincing evidence that uncemented femoral fixation has equally good results I do not believe that it has advantages for my patients.

Do you cement the stem?

I do cement the stem in patients with poor bone stock, with very small femoral components or patients I consider at particular risk for neck fracture. The literature seems to suggest that cementing the stem can reduce the risk of neck fracture in high risk patients. I also might consider cementing the stem in patients with avascular necrosis. However, I do not cement the stem in the majority of my patients.

Will you be preserving my hip capsule?

Yes. I preserve the capsule and repair it at the end of the procedure.

What anesthetic do you use?

At the Hospital for Special Surgery almost every Resurfacing Procedure is done using spinal anesthesia. This minimizes intraoperative blood loss, decreases the risk of blood clots and is also better tolerated by the patient than general anesthesia. I also use an intraoperative injection to minimize local pain

How long does the surgery take?

Usually the surgery takes approximately 1 hour.

What surgical approach do you use? Anterior or Posterior?

Posterior Approach.

What is the incision length?

12-20 cm.

What are the specific risks of hip resurfacing compared to standard hip replacement using a ceramic on plastic bearing?

A Hip Resurfacing is a metal on metal hip replacement. Because of its bearing components there are some specific risks to this type of surgery:

• Metallic Wear Particles: Aside from the usual and customary surgical risks, metal-on-metal hip implants carry additional risk. The implants are made of an alloy of Cobalt and Chromium (metals). The implants are made to be as frictionless as possible. However, everyday activities will inevitably create some friction and wear which can then result in metallic particles from the implant being released into the tissues surrounding the hip joint. In addition, residual matter from the metal particles is absorbed and circulated through the bloodstream.
• Pain, Swelling and Inflammation: In certain circumstances metal-on-metal implants may generate more metallic wear particles than usual, causing build-up of metallic wear particles around the hip. This may cause pain, swelling and inflammation around the hip joint (pseudotumor). Damage to the tissues around the hip joint is also possible. Revision surgery to remove the metallic wear particles and replace the metal-on-metal implant may be necessary to correct this problem.
• Allergic Reaction to Metal: Some patients have developed an allergic reaction to the metallic wear particles. The symptoms of an allergic reaction can be pain, swelling, and tissue damage. This can occur even when the amount of metallic wear particles is in the normal range. If a patient suffers an allergic reaction, revision surgery is necessary to remove and replace the implant. Currently, there is no proven test to predict the possibility of an allergic reaction.
• Organ Systems Issues: There have been reports of organ systems being affected, when metal ion levels in the bloodstream are higher than expected for a patient with a hip resurfacing implant. Vision, hearing, heart, brain and endocrine functions can also be affected. Some symptoms that have been reported include: blurry vision, loss of hearing, palpitations, loss of concentration, hypothyroidism and decreased heart and kidney functions. If these symptoms develop after surgery, revision surgery to remove the metal-on-metal implant is necessary.You need to understand that we do not know every risk of resurfacing.
• Fetal Development and Women of Childbearing Age: There is limited data on the effects of circulating metal ions in the bloodstream upon fetal development. Therefore, it is not recommended that women of child-bearing age have a metal-on-metal implant. If a woman of child-bearing age were to have metal-on-metal implant, it is recommended that the amount of metal ions in the blood be checked prior to getting pregnant.
• Patients with small bones and therefore smaller components, patients with misaligned components, women and patients with preexisting metal ion allergies might be at increased risk for above complications.

Although potential benefits of opting for a hip resurfacing over a total hip replacement include: higher post-surgical activity levels and reduced dislocation rates, it has to be assumed that revision rates are higher at 20 years compared to standard total hip arthroplasties.

What is your post-op protocol?

I start intensive range of motion early after surgery to make sure you do not get stiff. We will discuss the specific exercises while you are in the hospital. Usually by 3 weeks you should be able to have excellent flexibility.

I will keep you on crutches full weight bearing for the first 2 weeks to protect your femoral neck and allow it to adjust to the new implant.

Usually after 1 week you will not need any narcotic medication during the day. You can drive a car whenever you are comfortable and are off narcotic medications.

What hospital do you use?

Hospital for Special Surgery, 535 East 70th Street, NY 10021.

What is their infection rate?

0.3% for primary total joint replacement surgery.

Have any of your patients had infections that required IV antibiotics following resurfacing?

No, I have not had an infection following a hip resurfacing.

What drugs/methods do you use for anti-coagulation after surgery?

We use coated Aspirin 325mg twice a day for the majority of our patients. Please tell Dr. Boettner if you had a history of a blood clot or pulmonary emboli.

How long will I be in hospital?

1 – 3 days

When will I be 100% weight bearing?

We will let you put full weight on the hip right away.

Please contact our office if you have further questions regarding this treatment option.

When can I return to sport?

You can start exercising on a stationary bike by two weeks after surgery and can return to normal biking ca. 6-8 weeks after surgery. You can return to all sports without restriction 2 months after surgery. You can play golf 4-6 weeks after surgery after you saw Dr. Boettner in the office.

Are there limitations after hip resurfacing?

No, I let my patients return to all sport they did preoperatively. However patients need to understand that a resurfacing is a mechanical device and increased load might increase the failure rate at 10 and 20 years.