14. Q. On a surgeon’s stats, how can you find out how many times the surgeon has assisted or performed HR as the lead surgeon?
A. Ask them directly. How many resurfacing they have performed in the past year would also be instructive since volume develops technique.
Top
15. Q. How do you judge whether a new HR surgeon is competent? Especially one that doesn't have a big loyal following?
A. Find out how he learned resurfacing. Did he take a class, observe, scrub in and assist? Did he spend time with an experienced resurfacing surgeon? Has he done at least 50? What are the results?
Top
16. Q. How many HR surgeries does it take to overcome the HR learning curve?
A. This very much depends on the previous experience level of the surgeon, the amount of time spent with an experienced resurfacing surgeon and the rate at which the surgeon is implanting HR devices. For example one HR per month is probably not enough to develop great technique.
Top
17. Q. Do health insurance carriers cover the costs associated with hip resurfacing surgery?
A. Hip resurfacing is considered a “covered service” by Aetna and the Medicare intermediary here in California. The vast majority of all other national and regional insurance carriers are now authorizing. Our office will contact your carrier following your initial consultation The carrier will typically render a coverage decision within a relatively short period of time although the response time varies from carrier to carrier. If you are a Medicare beneficiary from another state and you undergo the surgery then the surgery would be covered by Medicare. The Medicare intermediaries in the other regions of the country make independent determinations of coverage for surgeries performed in those regions but there have been no recent denials.
Top
18. Q. What is the JRI surgeons’ opinion regarding the “mini-incision” surgical approach and is it used in hip resurfacing surgery?
A. There is considerable interest in minimally invasive surgery. However, one must distinguish between the so called “mini-incision” technique and “minimally invasive” surgery. At this time, consensus has not been reached on what constitutes “mini-incision” or how it is defined. Further, there is considerable variability in the length of incision used for the “standard” total hip. Although there is considerable enthusiasm, the efficacy of "mini-incision" techniques has not yet been demonstrated by appropriate scientific trials. Ideally, patients of similar characteristics would be randomized to a “standard” incision or a “mini-incision”. Establishing the efficacy of any new technique would require a favorable operative time (currently the mini takes longer), a lower blood loss, a shorter hospital length-of-stay, a faster return to work and other normal activities, as well as an equal rate of complications (wound healing, dislocation, infection, survivorship, etc.) – in a comparable group of patients with similar attitude and motivation. Therefore, in the “ideal” patient, the standard incision would be small and the patient would recover quickly but not due to the length of the skin incision, but rather because of the good starting material! At the present time neither safety nor efficacy have been established for “mini-incision” techniques. In fact, many centers report higher short-term complication rates and it is extremely unlikely that the long-term stability, wear, fixation and durability of THR using a mini-incision approach will be improved. At the JRI the incision length is adjusted according to the size and bulk of the patient and the type of procedure being performed although “mini-incision techniques” are not currently recommended for hip resurfacing due to the limited access and visualization of the hip joint that characterizes these approaches. Irrespective of the procedure, the most important variable is the quality of surgery being performed. It is unwise under any circumstances to compromise the visibility of the surgeon nor the best available implantation techniques as the primary goal is to optimize long-term durability.
Our advice to prospective hip replacement patients considering the “mini-
incision” is:
1. If your BMI [(weight (in kg) / height (in m)) squared] is less than
25, then the standard incision is so small that any benefit from a "mini
incision" is questionable.
2. If your BMI is 25 or more (getting more obese), and your hip is
stiff, the efficacy of the "mini incision" has not been demonstrated.
Basically, if you want a small incision, you need to be thin.
REMEMBER: A TOTAL HIP REPLACEMENT IS A TOTAL HIP
REPLACEMENT REGARDLESS OF THE SIZE OF THE INCISION. HIP
RESURFACING IS THE ONLY “MINIMALLY BONE INVASIVE”
TECHNIQUE BECAUSE YOUR FEMORAL BONE IS PRESERVED!
19. Q. What are the differences between the posterior and anterior surgical approaches?
A. Recovery is quicker with the posterior approach because no important muscle groups are sectioned. The posterior approach is also well-suited for patients who are large, well muscled or who require special techniques to implant the hip resurfacing socket.
In the past some surgeons changed from the posterior to the anterior approach to improve stability and reduce the incidence of dislocation after THR. This was effective when THR ball size was small (22,28,32mm). However the risk of dislocation is overcome by using larger ball sizes and at the JRI 36mm is generally the minimum so there is no advantage left to the anterior approach. Wear data now available supports the use of larger ball sizes from 36 mm up to 54mm with Metal on Metal technology and up to 40 mm with new cross-linked polyethylene. The largest ball size available for ceramic on ceramic bearings is 36 mm because a two part socket is required and ceramic material must be relatively thick to minimize the risk of fracture. Resurfacing is best performed with a posterior approach. However, even a hip resurfacing procedure can technically be performed in most individuals using an anterior approach but this requires removal of 33% to 50% of the abductor muscles. Even though the muscle group is reattached, the muscles are strong and, therefore, the reattachment may pull loose even if activities are restricted for a prolonged period.
Summary of Advantages - Posterior vs. Anterior Approach:
The posterior approach for hip resurfacing has the following advantages now
that the instrumentation has been redesigned specifically for that approach:
1. No important muscle groups are sectioned.
2. There is no release of the abductor muscles. They are the most important
muscles stabilizing the hip during walking and other activities.
3. The gluteus medius and minimus remain intact. The only muscle groups
that are released are the short rotators that are repaired at the conclusion of
the procedure. However, no important gait or other disturbances results
from a release even if they are not repaired because the rotation is
accomplished by other muscles. One of the two insertions of the gluteus
maximus tendon which extends the hip may be released in large obese or
very muscular individual but there is no resulting muscular weakness.
4. The new instrumentation facilitates a smaller incision especially in thin
individuals. A longer incision is necessary in well muscled or overweight
patients. A slightly longer incision is necessary in resurfacing than
when the head and neck are amputated in conventional THR. In hip
resurfacing the surgeon must work around the head and neck to be able to
prepare the acetabulum and implant the socket accurately. Hip resurfacing
is technically more demanding and takes slightly longer. Since hip
resurfacing is an anatomical replacement, leg length equalization is
facilitated and more precise. Leg length equalization in THR is more
demanding, less certain and requires an intra-operative X-ray.
5. The anterior approach requires removal of some of the abductor muscles
for either hip resurfacing or THR. Even though they are repaired this
reattachment may not be 100% successful.
TopPage 1 | Page 2 |
Page 3