Disclosures. ! Consultant. ! Stryker. ! Smith and Nephew. Why Resurface? ! Save bone the day of surgery. ! No bone loss from stressshielding
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1 Disclosures irmingham Hip Resurfacing Hip Resurfacing in 2015 Peter rooks MD, FRCS(C) Cleveland Clinic! Consultant! Stryker! Smith and Nephew HR Goals Why Resurface? Why Resurface?! Summarize benefits! Risks! Patient factors: indications! Results of HR! Recent developments! Save bone the day of surgery! No bone loss from stressshielding! Dislocations rare! No leg length problems! No thigh pain! Young, active patients! Proprioception maintained! Return to high activity! Potential for longevity! Easy to revise Calcar one Loss, THR vs HR Metallosis and Pseudotumor MOM Total Hip Replacement! Generally the most feared and talked about issue! Can be related to! Implant factors! Patient factors! Surgeon factors! Very popular 7-8 years ago! ig head, less dislocation! Small neck, great ROM! Turned out to be a disaster! Metal debris, pseudotumors! Gave MOM bearings a bad name 1%
2 MoM THR Morse Tapers Taper Corrosion! I do not recommend MoM THR! Highest failure rate of any bearing! Why? It s the Trunion!! Micromotion, fretting, corrosion! Fine for 28, 32! 50+: Too much torque for small diameter tapers! igger head -> more wear More metal debris than the bearing itself! Metallosis in Resurfacing Resurfacing is Different THR Socket Profile! There is no trunion! lways due to edge loading! Edge loading results in high wear! Not a mystery! Not an allergy! Easily understood! Sockets have less coverage than traditional THR sockets! Must be placed more horizontally! Size matters! igger is better! Opposite with MOM THR C,,C 45 HR Socket Profile Wear Patch Limes and Oranges 45 53! MoM wear patch is 440 mm 2! Regardless of the size of the bearing! lways the size of a quarter! This is why bigger is better 38 mm 58 mm 2%
3 Malposition & Edge Loading Normal Edge Wear What is the Risk?! McMinn series: 7/3200 pseudotumor (0.2%) all HR! Canada 3/3200 (0.1%)! Cleveland Clinic 1/2200 (0.05%) Female Male Prof. David Murray, Oxford ustralian Joint Registry 2013 Resurfacing Number Total % Follow-Up Cumulative Head / Cup revised Number Revised Years Revision Risk! March 2010 JJS! Pseudotumor cases sent for wear analysis! ll showed increased wear! 100% had edge wear! What would he have done?! resurfacing. Of course (CCJR Dec. 2010)! Repeated in 2012 SR HR xxxx Conserve Plus (2009) Cormet Durom Recap etter than THR in Young Men! Men are the best candidates for resurfacing! Larger size! Stronger bone! Fewer complications Males < yr Revision Risk Replacement 8.2% 7.7% ll, not just HR Resurfacing 6.1% 6.0% Females % 17.5% 2012 ustralian Registry HR is Unique! In 2015, HR is the only FDapproved resurfacing available in US, so comparisons don t matter now! Conserve +: Wright sold to Microport (China). No sales in US! Cormet: (Corin, formerly Stryker) withdrawn for 21% failure rate 3%
4 The SR Recall! Depuy MOM, THR and resurfacing! FD-approved as MOM THR! Never approved as a resurfacing! Terrible results in 93,000 cases! 25% resurfacing failures! 50% THR failures! Recalled in 2010 Why did the SR Fail?! Metallurgy! Socket Design! Clearance! Sphericity! Gave resurfacing a bad name SR Metallurgy! s-cast head! Double heat-treated socket! Weakened carbide microstructure! Different metallurgy ball and socket! Hard-on-soft bearing! HR is completely as-cast, harder SR Socket Design Groove for Impactor SR! Shallow socket! HR has 162 inner bearing Edge wear! SR had 145 in smaller sizes! Outlier SR Clearance Cup Deformation Low Clearance -> No Clearance! Cut clearance in half from historically successful bearings! 100 µ instead of ~ 200 µ! Expected to improve lubrication! Cup deforms on impaction! Finger and thumb = 30µ! Sawbones = 70µ! More in hard bone! Easily more than 100µ! 100 microns becomes zero! Equatorial clamping! No lubrication! High wear, pseudotumors 4%
5 Sphericity Roundness Deviation µ Poor Outcomes with SR Head Socket! Rounder is better! Less wear! SR had poor roundness! So do others HR SR and others HR SR Conserve Plus Cormet Durom Recap ! Combination of factors:! Metallurgy! Socket design! Clearance! Sphericity! They are not all the same The Implant Matters Mortality! Historical poor results of other resurfacing devices can be explained! Only the HR is available in US! Has the best data! HR in men has a lower death rate than THR! That s important! Very important if it s true 283,000 patients Conclusion! fter adjustment for all known risk factors, patient survival with HR is superior to uncemented THR, which in turn is superior to cemented THR nother Study: MJ 2013! 385,000 THR! 18,000 resurfacing! Survival advantage compared to Cemented THR: 1.0! Cementless THR 0.86! Resurfacing 0.52 Conclusion! Patients receiving hip resurfacing have reduced longterm mortality compared to patients receiving other types of hip replacement 5%
6 Why Lower Death Rate?! Persists even when corrected for age, gender, co-morbidities, socioeconomic status, rurality! llows greater post-op activity! Less fat embolism during surgery?! Stride length! Stride Length! Independent risk factor for Type 2 diabetes! Independent factor in longevity! ny THR, short stem, IM femoral nail decreases stride length! 9% slower walking speed! Resurfacing keeps it normal 9% is a Lot!! Usain olt, Olympic Sprinter! Fastest man in the world Secretariat, elmont 1973 Cancer Risk?? Cancer: MJ 2012! Concerns about this for many years! Decades-long studies! Scandinavia, UK! There is no evidence of an increased risk of cancer. Risk of Cancer? Cancer rates (Visuri) UK Registry 2012! Compared with alternative bearings, there was no evidence that metal-on-metal bearing surfaces were associated with an increased risk of any cancer diagnosis Exact same metallurgy as HR 6%
7 HR Results HRs Men$! McMinn series at 15 years! ll comers! ll diagnoses! Learning curve September 2014 First 1000 consecutive HR s NICE enchmark Women$ 85%$ yr Revision Risk CCF Hip Resurfacing Series Few Complications Males < ll, not just HR Replacement Resurfacing 8.2% 7.7% 6.1% 6.0% 15 yr HR McMinn 2% Females % 17.5% 8%! 2,200 HR s, 2006 present! 72% male! verage age 53 (12-84)! 91% O! No dislocations! No femoral loosening! 1 socket loosening! 2 deep infections Few Complications Survivorship in Young Men Lessons Learned! 2 femoral head collapse! 2 femoral neck fractures! 3 metal-related complications (0.1%)! 1 socket malposition! 1 excess anteversion! 1 pseudotumor! >99% survivorship up to 8 years 100% in 426 men < 50, up to 8 yrs! Similar to:! McMinn: 98% all men at 15 yrs! Treacy: 100% men, O < 50, 14 yrs! Murray: 99% men <50, 10 yrs! Patients are driving the volume! strong word-of-mouth! internet! Orthopedic surgeons who do no resurfacing may not mention it 7%
8 More Lessons Learned Pistol Grip Deformity! y far, the most common pathology is femoro-acetabular impingement! Un-noticed by total hip surgeons! Resurfacing can completely correct this Other Lessons Learned Conclusions Is Resurfacing Safe?! e careful with dysplasia! Excessive anteversion! Especially in small females! Resurfacing is very attractive to patients! Less attractive to surgeons! There are many ways to get into trouble! If you do it, you will become a better hip surgeon! No:! Poorly selected patient! Poorly done surgery! Poorly designed implant! Otherwise, Yes! Is it etter than THR? Is it etter than THR? eware Women and Small People! Fewer dislocations (1/10)! Less leg length problems! Higher functional activity! Saves bone on the femoral side! Keeps options open for the future! Lower revision risk in men up to 65! Lower death rate and cancer rate! YES! In young men 8%
9 NHL: Florida Panthers WWF: The Undertaker ML: Texas Rangers Colby Lewis 8 Months after Hip Resurfacing 9%
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