Patients who need a total hip replacement typically face a long, painful recovery period and loss of femoral bone structure. However, technological advances are providing patients with options that may allow them to avoid conventional hip replacement surgery and reduce the duration of recovery and future revision surgeries. Hip Resurfacing A revolutionary hip procedure known as the Birmingham Hip Resurfacing (BHR) technique is showing benefit for younger patients who are concerned about the possibility of multiple revision surgeries over their lifetime. “This is one of the most exciting procedures I’ve seen in years,” says Dr. Jeff Davis of Orthopaedic Specialists of Alabama and one of only two orthopedic surgeons in the state who is certified to perform the procedure. “I see hip resurfacing as the ideal solution for many young, active people who suffer from hip pain. As my patients get younger and younger and are staying physically active much later in life, I’ve needed an alternative to total hip replacement that accommodates their age and lifestyle. The Birmingham Hip Resurfacing system is that alternative.” Developed in Birmingham, England in the early 1990s, BHR is still considered a total hip replacement, but it conserves bone by leaving the femoral neck and head attached. With a conventional hip replacement, the entire femoral head and neck is removed. That bone conservation can be important if a patient requires revision surgery in the future, Davis says. “If the procedure does fail down the road, we can go in and take the cap off and do a standard hip replacement at that time. It’s much simpler than doing another total hip replacement,” he adds. With BHR, revision surgeries may not be needed as often because of the all-metal implant that is made from tough, smooth cobalt chrome and has the potential to last longer that traditional hip implants which use a metal ball and plastic socket that wears down over time and has to be replaced surgically. While Davis is certified to perform the BHR technique at Brookwood Medical Center, corporate issues had to be resolved before he was given the go-ahead to perform the surgery. Davis says that until Blue Cross and Blue Shield agrees to reimburse hospitals for this particular procedure, it may not be an option for patients at some hospitals. As of press time he had yet to perform the surgery on an actual patient but is anxious to get started. “My clinical experience is limited right now, but I’m ready to get up and running so I can offer this option to my patients,” he says. Dr. David Moore, an orthopedic surgeon at UAB, was the first physician in Alabama to be certified on the BHR system, and he has actually performed the procedure on four patients. He agrees that the procedure can benefit the right patient with the preservation of bone structure. “My experience with my patients is they had a slightly rougher immediate post-op course, but all were universally happy six weeks later and somewhat more active,” Moore says. “I’m not sure how much of that is related to the procedure or just because the patients were so sure they wanted the BHR.” Moore says his patients cited bone preservation and better range of motion as reasons they wanted the surgery. He agrees that both of those increase with BHR. He adds that they also wanted the surgery because they felt it was less invasive. “The surgery is actually more invasive because it currently requires more dissection than for the conventional total hip replacement,” he says. “I expect to see changes in the tools we use in the future, because I think the procedure lends itself well to computer-guided technology that would make it less invasive. We’re just not quite there yet.” Moore tells physicians that the BHR surgery is not difficult for someone who does a lot of hip revisions, “but for those who don’t have a strong hip practice it may be more daunting that the less invasive approach.” Moore is cautiously optimistic about the results that have been reported on the BHR. “We have about seven years of published data mostly from the United Kingdom and Australia, and it shows a 94-98 percent survival rate, which means the implant is still in place,” Moore says. “I’m encouraged about the early results I’ve seen, but we still have to wait and see about long-term outcomes.” Anterior Hip Replacement For those patients who still require a conventional hip replacement because of age or other factors, new minimally invasive total hip replacement technology is available at Princeton Baptist Medical Center. Known as anterior hip replacement, this surgery is done using a surgical table specially designed for minimally invasive orthopedic surgery. Princeton is the first hospital in Birmingham to use the hana™ Hip and Knee Arthroplasty Table, according to orthopedic surgeon Dr. Jack Featheringill. “The benefits of minimally invasive or anterior hip replacement are many,” says Featheringill, who has done about 40 of these surgeries. “Through the use of this table, we are able to better position the body, which allows us to make a smaller incision. That translates to less muscle trauma and a much faster recovery time for the patient. I am seeing my patients get up and around in a shorter amount of time with the anterior approach.” Using the special table, the surgeon can precisely position the patient’s lower body to allow access to the hip joint from the front or anterior side of the body as opposed to the side or back, Featheringill points out. This allows the surgeon to manipulate and replace the hip by working through the natural interval between the muscles without cutting into the muscle of the pelvis or femur. The most important muscles for hip function, the gluteal muscles attached to the pelvis and femur, are left undisturbed so no healing time is required. Additionally, this new positioning technology allows for x-ray imaging during surgery to more accurately control implant placement and leg length. Conventional lateral or posterior surgery requires the patient to adhere to strict recovery precautions. They must limit hip flexing, which complicates activities like sitting in a chair, putting on shoes and climbing stairs. The new anterior approach allows patients to immediately bend their hip freely and use their hip normally without cumbersome restrictions. This results in a more rapid return to normal function. “The anterior approach also lowers the risk of deep vein thrombosis because the leg is kept straight throughout the procedure. When doing the hip replacement from the back, the leg is twisted the whole time which increases the risk of DVT,” says Featheringill. The best candidates for anterior hip replacement are those who are having the surgery for the first time. Patients who have had previous hip replacements from the back will have to have hip revision surgery also from the back, says Featheringill. Because the hana™ table makes the surgery so much easier, Featheringill plans to perform all initial hip replacements using the anterior approach unless the patient has a previous problem. “I think this technology is a big improvement for hip replacements,” he says. “While it’s not the only way to do the surgery, it offers a quicker recovery and fewer risks.” October 2007