Orthopaedic surgeons who perform total hip arthroplasties—as well as those of us who are on the receiving end of those surgeries—owe a great deal to the immeasurable contributions of Sir John Charnley. Since his groundbreaking work, however, there have been numerous advances in prosthetic design, surgical techniques, and options for patients.
In this issue, AAOS Now explores the ongoing controversy concerning hybrid total hip arthroplasty versus hip resurfacing, including the indications, patient selection, and pros and cons of each. The literature contains several excellent articles (see www.aaos.org/now for links) detailing postoperative hip function, complications such as femoral neck fractures after each procedure, metal-on-metal articular wear, and the challenging learning curve for hip resurfacing. Each orthopaedic surgeon develops a personal set of criteria (including age, degree of arthritis, quality of bone stock, and amount of osteonecrosis) to evaluate patients and determine the most beneficial procedure.
But how about the “hip” patient? How does he (or she) fit into the decision-making process? After all, it is—or was—his (or her) hip. Shouldn’t patients have a say about whether they are too old, too young, too active, or too “hip”?
Although I’m anything but an expert on doing total hips, I am an expert—by virtue of receiving a total hip replacement—on the patient’s point of view. My total hip replacement is on the left side and it is the “flagship” of my other joints, better than either knee or my right hip. So I am a “hip” patient.
It’s the patient’s decision first
Before my surgery, I made the rounds: I studied the information available on the Internet; knew about metal-on-metal, cobalt oxinium, and cross-linked polyethylene; and found out where Birmingham, England, was. I had two consultants—James R. Urbaniak, MD, a hand surgeon from Duke University, and Dennis R. Wenger, MD, a pediatric orthopaedist from San Diego—who were also facing total hip replacements. (Urbaniak went first, I was second, and Wenger was third.) At various meetings, we would gather to discuss which procedure, which incision, which metal, which surgeon, which institution?
Although I had done all that research, I didn’t want to micromanage (much). As most patients do, I finally chose my surgeon and let him decide the rest for me. In my case, I actually had two surgeons (James L. Guyton, MD, and James W. Harkess, MD)—not because I’m special, but because it took two to put up with me.
My hybrid hip is now 3 years old, and, as a hip patient, I have four observations.
- I should have worried more about postoperative pain than about the type of metal, procedure, or approach. I often tell my residents that they each should have a total hip replacement or resurfacing as a rite of passage so they can experience what a patient’s pain is like after surgery.
- Although I don’t feel “cheated” because I did not get one of the currently popular resurfacing procedures, I’m not sure why resurfacing procedures can’t be done in older active patients (with the same indications as in young patients). I certainly am beyond the recommended 50- to 55-year-old age limit, but I’m pretty active, even though I have some arthritis on both sides of the joint. As we live longer and more active lives, “hip” patients should discuss their activity levels with their surgeons when determining which procedure to use.
- Most hip patients aren’t really concerned about the type of replacement they get. Of course, it really mattered to Drs. Urbaniak, Wenger, and me, because we knew just enough to be dangerous! I believe in shared decision making so that patients can make an informed decision, especially about whether they are ready for replacement or resurfacing. But, there are so many technical aspects to consider that for a patient to make a decision may be difficult. By and large, the surgeon’s comfort level and expertise with the procedure may be more important to the outcome than the device itself.
- Finally, the pain relief after a hip replacement (once you get beyond the immediate postoperative period) is so dramatic that most patients don’t even care what kind of device was used. I had a patient who had a femoral neck fracture and together we suffered through 3 years of a painful nonunion with osteonecrosis before she had a total hip replacement. One year after surgery, I asked her about it, and she replied that she couldn’t remember which hip had been replaced!
Ah! The luxury of choice
When Drs. Urbaniak and Wenger and I see each other at meetings now, we are hip! Urbaniak no longer limps, I no longer groan and moan, and Wenger no longer whines. Like my patient, I can’t even tell my operated hip from the natural one.
Furthermore, aren’t the outcomes and end results about the same for patients who have had their hips resurfaced and those who have had them replaced? In my case, why would I want a resurfacing procedure that would later require conversion to a total hip? Three days a week I jog (trudge) on a soft surface and do the elliptical machine, three days a week I play tennis (singles) on a soft surface, and on the seventh day I do all three (don’t tell my surgeons!). I have no pain and all the motion I need. Maybe I’m a fool or just naïve, but I do all I want and knock on cobalt every day that my hip doesn’t fall apart.
No other fields of medicine have advanced longevity and improved quality of life more than cardiac care (invasive and noninvasive) and orthopaedic surgery. As a patient, I have benefited from both. We—as patients and as surgeons—should be thankful that these two orthopaedic procedures are both so successful that the only “controversy” is which of two good options we should choose. In the end, it’s all about the patient’s hip and which procedure is right for each individual.