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Surgical options for the painful hip in young adults
The Round Table presented here continues the dialogue on treating painful hip conditions in young adult patients, which began in the December 2007 issue of Orthopedics Today. It addresses the decision-making process, implant selection, bearing material choices and navigation use in total hip arthroplasty through timely questions and responses from a diverse cross-section of experienced reconstructive hip surgeons.
Their responses are both dogmatic and questioning, but reflect the reality of a patient population that is expanding and whose longevity as well as the youthful onset of hip pathologies challenge arthroplasty solutions. This Round Table discussion presents a spectrum of conservative to aggressive strategies of which success will depend on a continual appreciation of patient and surgical variables as well as evolving design, material and manufacturing choices.
I would like to thank four busy and productive hip surgeons who have given freely of their time, experience and opinions.
A. Seth Greenwald, DPhil-(Oxon)
Moderator
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A. Seth Greenwald, DPhil-(Oxon)
Robert L. Barrack, MD
Joseph C. McCarthy, MD
Michael E. Berend, MD
Robert T. Trousdale, MDA. Seth Greenwald, DPhil-(Oxon): At the end of the day, when arthroplasty proves inevitable, what options do you consider?
Robert L. Barrack, MD: In the young adult in my practice, the major decision point is between total hip resurfacing with a modern era metal-on-metal component versus a cementless stem with an alternative bearing surface.
Michael E. Berend, MD: I currently consider total hip arthroplasty (THA) as the gold standard for the surgical reconstruction of the hip. Options to be considered in younger patients include alternative bearing surfaces such as highly crosslinked or enhanced polyethylene, ceramic, and metal-on-metal articulations coupled with the head size dialogue. I have gone to almost exclusively uncemented fixation on the acetabular and femoral side for fixation in primary THA and lean toward the use of large head technology regardless of articulation. I only have experience with revision of surface replacement procedures, but look forward to randomized and prospective studies examining comparisons between metal-on-metal large-head total hip replacement procedures and metal-on-metal surface replacement.
Joseph C. McCarthy, MD: I use minimally invasive hip replacement utilizing hard bearings and hip resurfacing in selected cases.
Robert T. Trousdale, MD: In patients with marked cartilage loss or end-stage hip disease in the face of structural problems, arthroplasty is the most reliable procedure. In the ultra-young patients depending on their age, I will occasionally use hard-on-hard bearing surfaces including ceramic-on-ceramic, metal-on-metal, and ceramic-on-metal in selective patients.
Greenwald: What impact has the recent FDA clearance of surface replacement systems had on your practice?
Barrack: Since the FDA’s clearance of surface replacement, a high percentage of young active patients younger than 60 years old, particularly males, have expressed an extreme amount of interest in this option. Only about half of the patients referred to me for consideration of this procedure turn out to be appropriate candidates. I was frankly surprised at the number of young patients in their 40s and 50s who were told long ago that they were candidates for hip replacement, but had a negative impression of that procedure and were waiting for an alternative. There seems to have been a large pent-up demand among young active patients in this category for an alternative to traditional THA.
Berend: Recent FDA clearance of surface replacement systems has generated some patient and surgeon interest in this technology. We have facilitated selective surgeons within our practice trying to obtain a clinical experience with this technology and have considered participating in multicenter studies examining the role of surface arthroplasty. I continue to have some concerns that without appropriate volumes to complete the learning curve and surgical experience, that surface replacement technology may not equal the short-, mid-, and long-term results of large head metal-on-metal total hip replacement with proven osseous fixation. The early fracture risk and influence of patient selection and surgeon training on the widespread application of this technology requires further investigation and well-controlled studies in my opinion.
McCarthy: It has increased the amount of time we spend teaching patients. The internet is full of misinformation about the differences in surgery, recovery and complications between THA and surface replacement.
Trousdale: The FDA clearance did not affect my use of surface replacement.
I have been doing surface replacements (in an off-label fashion) prior to the FDA approval. I perform resurfacing arthroplasty in very selective patients. Presently it constitutes less than 10% of my primary arthroplasty practice. The impact of the FDA clearance has been an increasing number of patients who inquire about the procedure, some of which are candidates for the procedure and others are not.
Greenwald: In your practice, what are the bearing materials of choice and why? Is cost a consideration?
Barrack: The two most attractive alternative bearing surfaces are metal-on-metal with a large head or crosslinked polyethylene with a scratch resistant head. I don’t believe cost is a major consideration since the idea is to extend the life of the arthroplasty by several years in a young healthy patient. The relative increase in implant cost is minor compared to the potential benefit as well as to the total cost of the procedure.
Berend: In my practice, I use predominately large head metal-on-metal bearing surfaces. I do this not so much for the bearing surface choice but rather the ability to obtain a large femoral head which decreases implant to implant impingement, decreases bearing wear while increasing impingement free range of motion which may reduce the risk of postoperative instability. Cost is a consideration in every center. We have not made patient-specific cost considerations, but rather activity level and life expectancy choices.
McCarthy: I prefer to use ceramic-on-highly crosslinked polyethylene or ceramic-on-ceramic in young patients. We avoid metal-on-metal in young women of child bearing age. Cost is always a consideration and is a collaborative discussion between physician, hospital and the patient.
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Trousdale: I use a host of different bearing materials depending on patient’s age, activity status, and medical considerations. Cost is really not a consideration as I choose the bearing surface that I think is the most optimal for that patient. I weigh the pros and cons of each of the bearing surfaces and discuss with the patient the bearing surface that I think is best for them based on the pro/con analysis. In the ultra young patient (teenage to 30s), I will use ceramic-on-ceramic; in the heavyset patient from 40 to 50 years old, I will use metal-on-metal or ceramic-on-metal (off-label); and in the patients over the age of 50 or 55 I use ceramic- or metal-on-highly crosslinked polyethylene. I still have some concerns about metal-on-metal and the metal ion issues in the ultra-young patients I am avoiding metal-on-metal bearing surfaces in that group.
Greenwald: For the young patient, what is your preferred femoral stem geometry, stiffness and surface coating?
Barrack: For young patients, I prefer a tapered titanium, proximally coated relatively short stem. I prefer a traditional sintered-bead coating for the proximal third and a textured surface in the middle third. As far as acetabular designs, I still prefer a hemispherical titanium component with a polished inner surface with the option for screw fixation which I usually utilize.
Berend: My preferred stem geometry for young patients continues to be a tapered titanium, circumferentially porous, plasma spray-coated implant. The minimum 10-year results of various stem geometries with these characteristics are almost 100%. I believe it is the most reliable fixation modality that preserves proximal bone of which I am aware. Our results published by John Meding, MD, were excellent. With regard to acetabular design requirements, I have been using mono-block metal-on-metal components for over 90% of my primary total hip replacements for the past 4 years and have found that a mono-block component with radial fins and a hemispherical design has proven to be reliable in my hands. I have steered away from elliptical designs due to the higher fracture risk and difficulty assuring full seating of the implant.
McCarthy: I prefer a titanium tapered femoral stem that is proximally circumferentially coated, preferably with a biologic coating such as hydroxyapatite. Occasionally a modular stem is needed for patients with versional deformities as seen in moderate to severe dysplasia, for which I prefer a modular hemispherical ingrowth acetabular component.
Trousdale: I use an uncemented acetabular component in young patients. Depending on what type of component I am using it as either a modular or a one-piece component. In the majority of patients I use a proximally coated uncemented tapered femoral stem.
Greenwald: Do MIS and computer navigation have a role in the surgical treatment of the young patient?
Barrack: The current evidence for substantial advantage of MIS and computer navigation over standard THA is not very strong. A relatively small number of patients are requesting MIS in my practice and I have not noticed a substantial clinical advantage in the cases in which I have utilized MIS. Having performed a large number of hip resurfacings in the past year with a larger than average incision than I had been utilizing for a standard THA, I have noticed that these patients with larger incisions have no more pain and many, in fact, have less perioperative pain and discomfort than patients with smaller incisions. Nevertheless, I think most of us have decreased our incision size from a previous standard of 8 or 10 inches down to 5 or 6 inches. I don’t think the evidence is very strong that going down to a 3 or 4 inch incision adds additional clinical benefit to justify the additional risk. I have observed substantial negatives in the form of referrals of significant complications from community surgeons who have struggled through small incisions and ended up with malpositioned components that required revision for either instability or early loosening.
Berend: I believe that safe, less-invasive surgery has a benefit to all patients; however, it must be taken in context of the risk-benefit ratio of smaller incisions on implant placement in the long-term performance of the implant in younger patients that have a longer life expectancy.
We have no experience with computer navigation and its biggest role in hip surgery has yet to be defined. I think we have all seen the potential positive benefits of the systematic approach to less invasive surgery with changes in the anesthetic protocols, perioperative pain management, and more rapid return to activity over the past 5 years. The negatives of implant positioning problems, bone defects created through asymmetric acetabular reaming, femoral fractures, trial implants left behind, abductor deficiency, and nerve injury are all things that each individual surgeon has to weigh the risks and benefits of less invasive technique upon their practice and patients.
McCarthy: I have used navigation in the past, but I do not use computer navigation at this point in time. I use a mini posterior muscle sparing approach which has resulted in a shorter recovery time and consistently positive surgical outcomes.
Trousdale: I presently do not use computer navigation for the majority of my patients. I think it has a role, especially in resurfacing for the placement of potential acetabular and femoral components and in primary total hip replacement for the placement of the acetabular component. The computer may be helpful to maximize the amount of correction. Presently I would feel that would be a research tool in joint salvage surgery.
Greenwald: What are your typical postoperative rehabilitation and follow-up protocols for this active class of patients?
Barrack: Postoperative protocols are fairly aggressive for young active patients. They are typically ambulating on the day of surgery weight-bearing as tolerated and most of them are leaving the hospital on the second day or occasionally the third day. Most utilize support for only 2 to 3 weeks.
Berend: The activity level and age of our patients does not typically change postoperative rehabilitation protocols and follow-up protocols in our practice. We believe that standardization has great benefits for the surgeons, patients, and the hospitals. We work closely with our anesthetic team for coordination of perioperative blocks, local anesthetic utilization, use of anti-inflammatories, and rapid conversion to oral narcotics. Our physiotherapy department begins rapid ambulation with full weightbearing in the majority of patients the day after surgery and our length of stay has been reduced down to below 2.5 days.
McCarthy: Postoperatively they are weightbearing as tolerated. We begin outpatient physical therapy as soon as they are able to drive which is typically 2 to 3 weeks. They are seen in the office at 6 weeks, 12 weeks, 6 months, 1 year, and thereafter annually.
Trousdale: For young and active patients, I typically let them weightbear as tolerated with some simple hip muscle exercises. Depending on the joint salvage surgery, they are typically touch weightbearing for 4 to 6 weeks at which time I let them weightbear as tolerated and begin low-impact exercise. I let most of my arthroplasty and joint salvage patients do most activities. I discourage repetitive high-impact activities in all of my patients and encourage aerobic exercise, low-impact activities such as bike riding, elliptical training, water exercises, downhill skiing, cross-country skiing, etc.
Greenwald: Lastly, what are your early and/or intermediate term follow-up conclusions for the young adult patient population you have treated?
Barrack: My ultra short-term experience with hip resurfacing performing it on a regular basis for a little over a year has been extremely satisfying. The complication rate has been low and patient enthusiasm and acceptance has been extremely high. The follow-up time is too short to draw any scientific conclusions, but we do have study protocols underway to carefully follow these patients. The intermediate term results of tapered titanium stems with alternative bearing surfaces are extremely promising. The wear rates with cross linked polyethylene in patients under 50 years old in the mid-term has been extremely low as has been the incidence of lysis.
Berend: Our early and intermediate conclusions from the young adult population continues to be that uncemented fixation has proven durable on both the femoral and acetabular side, that instability and infection continue to be the main problems and hopefully bearing surface changes will prove a few decades from now to be beneficial. Our minimum 10-year results with tapered titanium stems showed a 100% survivorship and a reduction in dislocation with larger femoral heads. We hope that further investigation of young more active patients with total hip replacements will result in further understanding of activity limits of patients for all ages with regard to hip preservation and arthroplasty techniques.
McCarthy: The hip arthroscopy patients do extremely well in the absence of extensive chondral damage. They resume running and high-impact sports following a 1- to 3-month recovery period. The total hip patients resume very active life styles including tennis, skiing, skating, hiking and biking after their initial recovery period.
Trousdale: I have been very pleased in the young adult population surgical group. I find that the realignment osteotomy patients, whom I care for, with dysplasia in the absence of secondary arthritic changes do extremely well both clinically and radiographically. Impingement surgery which involves both acetabular and femoral procedures, has been a little bit less reliable as the majority of these patients have some chondral problems present. I sense the results are related to the severity of the secondary chondral damage that is present: the more severe the chondral damage, the less optimal the result.
For more information:
- Robert L. Barrack, MD, can be reached at Washington University School of Medicine, 660 S. Euclid, Campus Box 8233, Dept. of Orthopedic Surgery, St. Louis, MO 63110; 314-747-2562; e-mail: barrackr@wustl.edu. He teaches/speaks on behalf of Smith & Nephew Orthopaedics.
- Michael E. Berend, MD, can be reached at the Center for Hip & Knee Surgery, 1199 Hadley Road, Mooresville, IN 46158; 317-831-2273; e-mail: mikeberend@hotmail.com. He is a consultant and receives research grants and royalties from Biomet.
- A. Seth Greenwald, DPhil (Oxon), can be reached at Orthopaedic Research Laboratories, Lutheran Hospital, a Cleveland Clinic hospital, 1730 West 25th St., Cleveland, OH 44113: 216-523-7004; e-mail: seth@orl-inc.com.
- Joseph C. McCarthy, MD, can be reached at Massachusetts General Hospital, 55 Fruit St., Boston, Massachusetts 02114; 617-726-3865; e-mail: jcmccarthy1@partners.org. He receives research or institutional support from and is a consultant or employee of Stryker Orthopaedics, Arthrex Corp., and Innomed and is a consultant or employee of United Health Care.
- Robert T. Trousdale, MD, can be reached at Mayo Clinic, 200 First Street SW E14B, Rochester, MN 55905; 507-284-3663; e-mail: trousdale.robert@mayo.edu.He has no direct financial interest in any products or companies mentioned in this article.