Birmingham Hip Resurfacing System
Patient Guide
BIRMINGHAM HIP Resurfacing
Who is a Candidate for Hip Resurfacing? Diseases of the Hip
Non-surgical Alternatives to Hip Resurfacing
The Procedure
The Implant
Hip Resurfacing: Pre-op & Surgery Day
Hip Rehabilitation After Surgery
Preventing Hip Resurfacing Complications
Frequently Asked Questions
BIRMINGHAM HIP Resurfacing System
Because this technologically advanced surgical procedure resurfaces rather than replaces the end of your femur (thighbone), you may participate in more strenuous physical activity with an implant that is potentially more stable and longer-lasting than traditional total hip replacements and if future revision surgery is required, it may be a less complex and less traumatic procedure.
In fact, a 1,626-hip study of the effectiveness of the technique found that 99.5-percent of patients responded they were “pleased” or “extremely pleased” with the results of their BIRMINGHAM HIP Resurfacing surgery.
Who is a Candidate for Hip Resurfacing?
Hip resurfacing is intended for young, active adults who are under 60 years of age and in need of a hip replacement. Adults over 60 who are living non-sedentary lifestyles may also be considered for this procedure. However, this can only be further determined by a review of your bone quality.
There are certain causes of hip arthritis that result in extreme deformity of either the head of the femur or the acetabulum (hip socket). These cases are usually not candidates for hip resurfacing.
Talk with your orthopaedic surgeon to determine if hip resurfacing is the right option for you.
Diseases of the Hip
Osteoarthritis
Osteoarthritis of the hip is a disease which wears away the cartilage between the femoral head and the acetabulum, eventually causing the two bones to scrape against each other, raw bone on raw bone. When this happens, the joint becomes pitted, eroded and uneven. The result is pain, stiffness and instability, and in some cases, motion of the leg may be greatly restricted.
Causes: Osteoarthritis of the hip is a condition commonly referred to as “wear and tear” arthritis. Although the degenerative process may accelerate in persons with a previous hip injury, many cases of osteoarthritis occur when the hip simply wears out. Some experts believe there may exist a genetic predisposition in people who develop osteoarthritis of the hip. Abnormalities of the hip due to previous fractures or childhood disorders may also lead to a degenerative hip. Osteoarthritis of the hip is the most common cause for both total hip replacement and hip resurfacing.
Symptoms: The first and most common symptom of osteoarthritis is pain in the hip or groin area during weight bearing activities such as walking. People with hip pain usually compensate by limping, or reducing the force on the arthritic hip. As a result of the cartilage degeneration, the hip loses its flexibility and strength, and may lead to the formation of bone spurs. Finally, as the condition worsens, the pain may be present all the time, even during non weight-bearing activities.
Rheumatoid Arthritis
Unlike osteoarthritis, which is a “wear and tear” phenomenon, rheumatoid arthritis is a chronic inflammatory disease that results in joint pain, stiffness and swelling. The disease process leads to severe, and at times rapid, deterioration of multiple joints, resulting in severe pain and loss of function.
Causes: Although the exact cause of rheumatoid arthritis is unknown, some experts believe that a virus or bacteria may trigger the disease in people having a genetic predisposition to rheumatoid arthritis. Many doctors think rheumatoid arthritis is an autoimmune disease in which the synovial tissue of the joint is attacked by one’s own immune system.
Symptoms: The primary symptoms of rheumatoid arthritis are similar to osteoarthritis and include pain, swelling and the loss of motion. In addition, other symptoms may include loss of appetite, fever, energy loss, anemia, and rheumatoid nodules (lumps of tissue under the skin). People suffering with rheumatoid arthritis commonly have periods of exacerbation or “flare ups” where multiple joints may be painful and stiff.
Developmental Dysplasia of the Hip
Developmental dysplasia of the hip (DDH), also called hip dysplasia, is a lifelong condition, shared by one in 1,000 people. Because DDH patients are born with an altered hip anatomy, the joint doesn’t develop the normal wear patterns over the years. This leads to “wear and tear” arthritis at a relatively early age.
Diagnosis: Developmental dysplasia of the hip often can be diagnosed in the first year of life.
Symptoms include diminished leg movement in the affected hip, shortening of the leg on the affected side, or asymmetry in leg positions. One or both hips may have DDH.
Avascular Necrosis
Avascular necrosis (AVN) of the hip results when poor blood circulation starves the bones that form the hip joint. In time, the starved bone dies, and the hip joint collapses.
AVN, sometimes called hip osteonecrosis, is most prevalent in younger or middle-aged adults.
Symptoms: Hip pain, especially after standing or walking, is the most common symptom. Hip AVN most commonly afflicts the femoral head, where the femur (or thighbone) attaches to the pelvis (or hip bone). The femoral head may weaken and collapse.
Non-surgical Alternatives to Hip Resurfacing
Lifestyle Modification
The first alternative to hip replacement involves such lifestyle modification measures as weight loss, avoiding activities involving long periods of standing or walking, and the use of a cane to decrease the stress on the painful hip.
Exercise and physical therapy may be prescribed to improve the strength and flexibility of your hip and other lower extremity muscles. Your exercise program may include riding a stationary bike, light weight training and flexibility exercises. An aquatic therapy program is especially effective for the treatment of arthritis since it allows mild resistance while removing weight bearing stresses. For an appropriate exercise program, contact an experienced physical therapist.
Arthritis pain is primarily caused by inflammation in the hip joint. Reducing the inflammation of the tissue in the hip can provide temporary relief from pain and may delay surgery.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) may be prescribed to decrease the inflammation associated with arthritis. A new classification of NSAIDs, called Cox-2 inhibitors, are often very effective in decreasing pain.
In a small number of cases, the doctor may prescribe corticosteroids, such as prednisone or cortisone, if NSAIDs are not effective. However, due to the higher rate of side effects associated with corticosteriods, a physician must closely monitor their use.
Glucosamine/Chondroitin
Two dietary supplements, Glucosamine and Chondroitin (commonly available in a combined tablet), may decrease the symptoms of hip arthritis. Glucosamine and Chondroitin sulfate are both naturally occurring molecules, and issues associated with both remain under active research. However, it appears that many people taking these nutrition supplements on a regular basis note a decrease in their arthritis symptoms.
Non-Surgical Alternatives
The Procedure
As you may know, total hip replacement requires the removal of the femoral head and the insertion of a hip stem down the shaft of the femur. Hip resurfacing, on the other hand, preserves the femoral head and the femoral neck. During the procedure, your surgeon will only remove a few centimeters of bone around the femoral head, shaping it to fit tightly inside the BIRMINGHAM HIP Resurfacing implant.
Your surgeon will also prepare the acetabulum for the metal cup that will form the socket portion of the ball-and-socket joint. While the resurfacing component slides over the top of the femoral head like a tooth cap, the acetabular component is pressed into place much like a total hip replacement component would be.
The Implant
The BIRMINGHAM HIP Resurfacing implant is not brand new. It has been in use around the world since 1997 and has since been implanted more than 60,000 times. It is new to the United States, however, where it was approved for use by the Food and Drug Administration in May 2006.
Patient Benefits
The benefits to patients of the BIRMINGHAM HIP Resurfacing technique and implant are clear. The implant’s head size, its bearing surfaces, and its bone-sparing technique make it a preferred choice for young, active patients. While the implant’s rate of survivorship is comparable to standard total hip replacements after five years, these three key advantages set the resurfacing technique and implant apart from its total hip replacement counterparts.
Healthy hip > BHR implant > Total hip
Dislocation is a leading cause of implant failure in total hip replacement. While total hip implants dislocate at a rate of one to three-percent over the lifetime of the implant, a study of 2,385 BIRMINGHAM HIP Resurfacing patients found that dislocation occurred in only 0.3-percent of cases five years after surgery.
BIRMINGHAM HIP Resurfacing takes advantage of one of the orthopaedic medical industry’s most technologically advanced bearing surfaces. That means that the surfaces of the ball and the socket are made from materials that dramatically reduce joint wear when compared to traditional hip implant materials.
In this case, both the ball and socket are made from tough, smooth cobalt chrome metal. Traditionally, only the ball is made from cobalt chrome, and the socket is lined with a plastic cup. While this plastic cup has some design advantages, it does wear out over the course of many years since it rubs against the metal ball at a rate of nearly two million footsteps per year in physically active adults.
The plastic particles released into the area around the joint as a result of this plastic wear can lead to a condition called osteolysis, which causes the bone around the implant to soften, become unstable, and ultimately a corrective surgery and new implant are required.
There may be risks associated with metal-on-metal hip implants, though. While no evidence has been established on the subject, some are concerned that the increased level of metal ions found in the blood of metal-on-metal hip recipients may have negative effects on the human body. For this reason, some surgeons may not implant such a device in a patient with kidney disease (since healthy kidneys filter ions from your body) or in women who are or may become pregnant.
Bone Conservation
Perhaps the greatest benefit of the BIRMINGHAM HIP Resurfacing implant is the fact that it conserves substantially more bone than a total hip replacement. This is important for two key reasons.
BHR cuts > Total hip cuts
Second, if your surgeon should determine you need to have your BIRMINGHAM HIP implant replaced at some point in the future, you may undergo a regular total hip replacement surgery. If you had originally undergone total hip replacement instead of hip resurfacing, you would be dealing with a more traumatic and complex procedure and you would be receiving a more invasive implant.
Hip Resurfacing: Pre-op & Surgery Day
Once you and your orthopedic surgeon decide that hip resurfacing is right for you, the days and weeks leading up to surgery, as well as the day of surgery, require preparation. The following is a description of what you may expect.
Pre-operative Procedure
You and your orthopedic surgeon may participate in an initial surgical consultation. This appointment may include pre-operative X-rays, a complete medical and surgical history, physical examination, and a comprehensive list of medications and allergies. During this visit, your orthopedic surgeon will likely review the procedure and answer any questions.
Preparation for the Hospital
You may want to bring the following items to the hospital:
• Clothing underwear, socks, t-shirts, exercise shorts for rehabilitation
• Footwear walking or tennis shoes for rehab, slippers for hospital room
• Walking aids: walker, cane, wheelchair, or crutches if used prior to surgery
• Insurance information
• You should follow your regular diet on the day before your surgery.
• DO NOT EAT OR DRINK AFTER MIDNIGHT the night before surgery. On the morning of surgery, you may brush your teeth and rinse your mouth, but do not swallow any water.
• Follow your doctor's instructions regarding use of medication in the days leading to surgery. In some cases, a blood thinner may be ordered a few days before surgery. Generally, aspirin and non-steroidal anti-inflammatory medications should not be taken seven days prior to surgery.
• Try to get long, restful nights of sleep. A sleeping medication may be ordered the evening before surgery.
Day of Surgery
On the morning of surgery, once you are admitted to the hospital, you will be taken to the appropriate pre-surgical area where the nursing staff will take your vital signs, start intravenous (IV) fluids, and administer medications as needed. You will be asked to empty your bladder just prior to surgery, and to remove all jewelry, contacts, etc. (Rings not removed will be taped.) Once you change into a hospital gown, you will be placed on a stretcher, and transported to the operating room. The anesthesiologist will meet you and review the medications and procedures to be used during surgery.
When surgery is completed, you will be taken to the recovery room for a period of close observation. Your blood pressure, heart rate, respiration, and body temperature will be closely monitored by the recovery room staff. Special attention will be given to your circulation and sensation in your feet and legs. When you awaken and your condition is stabilized, you will be transferred to your room.
1. A large dressing may have been applied to the surgical area.
2. You may see a hemovac suction container with tubes leading directly into the surgical area. This device allows the nurses to measure and record the amount of drainage from the wound following surgery.
3. An IV will continue post-operatively in order to provide adequate fluids. The IV may also be used for administration of antibiotics or other medications.
4. A catheter may have been inserted into your bladder as the side effects of medication often make it difficult to urinate.
5. An elastic hose may be applied to decrease the risk of deep vein thrombosis (DVT). A compression device may also be applied to your feet to further prevent DVT.
6. A patient-controlled analgesia (PCA) device may be connected to your IV, allowing you to control the relative amount and frequency of pain medication. To prevent overdose, the unit is programmed to deliver a pre-defined amount of pain medication anytime you press the button of the machine.
Preventing Hip Resurfacing Complications
As with any major surgical procedure, post-operative complications can occur following hip resurfacing surgery. Below is a list of some of the more common complications that can occur after hip resurfacing surgery. This list is not meant to be all-inclusive.
This condition, which includes two interrelated conditions—deep vein thrombosis and pulmonary embolism—occurs when blood clots are formed in the large veins of the legs. In some cases, these clots can become dislodged from the veins, travel through the circulatory system, and become stuck in the critical arteries of the lungs. This scenario, called a pulmonary embolism, is a serious medical condition.
1. Blood-thinning medication (anticoagulants, aspirin)
2. Elastic stockings (TED hose)
3. Foot elevation to prevent swelling
4. Foot and ankle exercises to optimize blood flow.
5. Pneumatic devices placed on the feet to improve circulation.
IMPORTANT: If you develop swelling, redness, pain and/or tenderness in the calf muscle, report these symptoms immediately to your physician.
Infection
Infections occur in a small percentage of patients undergoing hip resurfacing surgery. Unfortunately, infections can occur even when every effort is made to prevent them.
1. Closely monitor the incision and immediately report signs of redness, swelling, tenderness, drainage, foul odor, increasing pain or persistent fever.
2. Always wash your hands before and after handling your incision site, especially when the sutures are still in place.
Pneumonia
A possible side effect of surgery is the development of pneumonia.
The following steps may help minimize this risk:
1. Deep breathing exercises. A simple analogy to illustrate proper deep breathing is to: “smell the roses...and blow out the candles.” In other words, inhale slowly and deeply through your nose, and exhale slowly through your mouth at a slow and controlled rate. A simple rule of thumb may be to perform these deep breathing exercises 8-10 times every waking hour.
2. Coughing. This activity helps to loosen the secretions in your lungs and excrete the from your pulmonary system.
3. Incentive spirometer. This simple device provides visual feedback while performing deep breathing exercises. Your nurse or respiratory therapist will demonstrate the proper technique.
Frequently Asked Questions
While the BIRMINGHAM HIP Resurfacing implant is new to the United States, it is not a new implant or technique. It has been in use worldwide since 1997, and the US Food and Drug Administration reviewed a tremendous amount of resulting clinical data before approving it for use in this country.
The typical patient will be physically active, under 60 years of age, and suffering from hip arthritis, hip dysplasia or avascular necrosis of the hip. The implant can be used in patients over 60 whose bone quality is strong enough to support the implant. Your surgeon will make the determination if you are a candidate for hip resurfacing.
It is impossible to say how long your implant will last because so many factors play into the lifespan of an implant. In the case of resurfacing, for instance, the metal-on-metal bearing surfaces of your new joint may extend its life longer than that of a traditional total hip replacement, but failure to comply with your physical rehabilitation regime may cause your implant to fail within months. A clinical study showed the BIRMINGHAM HIP Resurfacing implant had a survivorship of 98.4-percent at the five-year mark, which is comparable with the survivorship of a traditional total hip replacement in the under-60 age group.
Your surgeon will use an incision of between six and eight inches in length. While some surgeons may use a slightly smaller incision, most will fall in that range.
Most surgeons will tell you that after the first year, you can return to whatever physical activity you enjoyed before hip pain limited your mobility. For instance, unlike total hip replacement, you will be able to return to jogging or singles tennis after your first year after surgery. During your first year, more conservative, low-impact activities like walking, swimming and bicycling are recommended for strengthening your femoral neck and the muscles around your resurfaced joint.
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